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MEDICAL *AND DENTAL 

SPACE JMglT 

A COMPREHENSIVE GUIDE TO DESIGN. EQUIPMENT, AND CLINICAL PROCEDURES 



MEDICAL AND DENTAL 

SPACE PLANNING 

A Comprehensive Guide to Design, Equipment, 
and Clinical Procedures 



THIRD EDITION 



Jain Malkin 




JOHN WILEY & SONS, INC. 



MEDICAL AND DENTAL 

SPACE PLANNING 



MEDICAL AND DENTAL 

SPACE PLANNING 

A Comprehensive Guide to Design, Equipment, 
and Clinical Procedures 



THIRD EDITION 



Jain Malkin 




JOHN WILEY & SONS, INC. 



Cover Credits 

Gowned Waiting Lounge: 
Scripps Polster Breast Center 
Design: Jain Malkin Inc. 
Photographer: Glenn Cormier, InSite 

Dental Operatory: 

Design: Lawrence Man Architects 

Photographer: Lucy Chen 

Screened Background Rendering: 

Courtesy Janice Thayer-Johnson, Signature Environments 



Copyright © 2002 by John Wiley & Sons, New York. All rights reserved. 

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form 
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To Stuart, 

for his good cheer, enduring patience, 

and encouragement throughout the two years 

of researching and writing this book, 

a task that seemed as if it would never end 



And in memory of my Mother, 

whose energy and drive, love for the written word, 

and intellectual curiosity have shaped my life 



Contents 



Preface ix 

Introduction Changing Perspectives xiii 

Chapter 1 Psychology: Implications for Healthcare Design 1 

Overview, Patient Satisfaction, Consumer Perceptions of 
the Healthcare Environment, The New Consumerism, First 
Impressions Count, Waiting: A Frustrating Inconvenience, 
Perceived Status Difference, Seeing the Doctor as a 
Person 

Chapter 2 General Parameters of Medical Space Planning 7 

Building Shell Design, Planning Module, Amenities, 
Building Shell Configurations, Building Standards, 
Tenant Improvement Allowances, Politics, Leasing 
Considerations, Hospital-Based MOBs 

Chapter 3 Practice of Medicine: Primary Care 20 

Family Practice, Internal Medicine, Pediatrics 

Chapter 4 Medicine: Specialized Suites 105 

Surgical Specialties, Obstetrics and Gynecology, 
Women's Health Centers, Breast Centers, Reproductive 
Enhancement, Oncology, General Surgery, Otolaryngology, 
Ophthalmology, Plastic Surgery, Dermatology, Orthopedic 
Surgery, Allergy, Neurology, Neurosurgery, Pain 
Management Centers, Psychiatry, Urology 

Chapter 5 Diagnostic Medicine 243 

Diagnostic Imaging, Ultrasound, Nuclear Medicine, 
Computed Tomography, Mammography, Radiation 
Oncology, Magnetic Resonance Imaging, Clinical 
Laboratory 



Chapter 6 Group Practice 311 

Stark Statute, Accreditation, Types of Group Practices, 
Primary-Care Clinics, Health Maintenance Organizations, 
Point-of-Service (POS), Single-Specialty Group, 
Multispecialty Group, Internal Medicine Group, Family 
Practice Group 

Chapter 7 Ambulatory Surgical Centers 334 

Overview, Advantages of Ambulatory Surgery, Ownership 
and Affiliation, Economic and Regulatory Issues, 
Marketing Considerations, Survey of Surgical Procedures, 
Trends and Innovation, Facility Design, Operational 
Protocols, Patient Flow, Facility Access, Individual 
Components of an FOSC, Recovery-Care Centers, Types 
of Procedures Necessitating Extended Care, Summary 

Chapter 8 Sports Medicine 368 

Overview, Case Studies 

Chapter 9 Paramedical Suites 385 

Physical Therapy, Pharmacy 

Chapter 10 Practice of Dentistry 401 

High-Touch Patient Amenities, Interview Questionnaire — 
An Important Design Tool, Plan the Space Before Signing 
a Lease, Codes and Regulatory Agency Review, New 
Technology Transforms the Dental Office, Infection 
Control, General Dentistry, General Dentistry: 
Prosthodontics Emphasis, Esthetic/Cosmetic Dentistry, 
Technology Resource, Relevant Information in Other 
Chapters of the Book, Orthodontics, Pediatric Dentistry, 
Endodontics, Periodontics, Oral and Maxillofacial Surgery, 
Summary 



VII 



Chapter 11 Impact of Color on the Medical Environment 516 Chapter 15 

Introduction to Color Theory, Color Preference Tests, 
Color-Form Preference, Color and Mental Disorders, 
Biological Effects of Color, Color and Personality, Color 
and Harmony, The Color Wheel, Laws of Perception, Color 
Symbolism, Practical Applications of Color Psychology, 
Color and Its Effect on Our Perception of Space, 
Summary 

Chapter 12 Interior Finishes and Furniture 529 

Hard-Surface Flooring, Carpet, Wall Treatments, Furniture, 

Upholstery Fabric Appendixes 

Chapter 13 Lighting 545 

Biological Effects of Light, Technical Data, Innovation and 
Trends, Energy Conservation, Medical Office Electrical 
and Lighting Requirements 

Chapter 14 Construction Methods and Building Systems 556 Index 

Heating, Ventilating, and Air Conditioning, Control of 
Odors, Plumbing, Medical Gases, Medical/Dental Office 
Communication Systems, Fire Protection, Checklist 



Researching Codes and Reference Materials 562 

Fire Protection, The Americans with Disabilities Act of 
1990, Sanitation, Minimum Construction Requirements, 
Energy Conservation/Environmental Impact, Certificate of 
Need, Issues Relating to Outpatient Medical Facilities 
Under a Hospital's License, Codes Relating to Medical 
Office Buildings, Isolation of Risk, Required Exits, 
Separation of Exits, Stairs and Doors, Fire-Warning or 
Fire-Extinguishing Devices, Flammability Testing, Carpet, 
Wallcoverings 

Handicapped Accessible Toilet 570 
Suggested Mounting Heights for View Box 

Illuminators 573 
Specimen Pass-Through 574 
Medical Space Planning Questionnaire 575 
Dental Space Planning Questionnaire 579 



583 



VII 



Contents 



Preface 



In 1970, I decided to specialize in healthcare design. 
I spent many weeks at the library researching the litera- 
ture on medical and dental space planning, color and its 
effect on patients, and the psychological aspects of ill- 
ness — how do patients and visitors react to hospitals? 
Why do people fear a visit to the doctor or dentist? What 
role does lighting play in patient rooms? 

Much to my surprise, very little had been written on 
these topics. I found nothing in architecture or design 
publications, but did come across an occasional article in 
obscure publications sometimes dating from the 1940s. 
There were a few articles in the American Journal of 
Occupational Therapy on the effect of the environment 
on the patient, and there were numerous articles on 
color preferences of various ethnic groups or cultural 
taboos with respect to color. A handful of articles on lim- 
ited aspects of office space planning were scattered in 
medical or dental practice management magazines and 
Department of Health, Education, and Welfare publica- 
tions. Here was a field with few resources and vast 
potential. 

Most medical and dental offices in 1970 were either 
colorless and clinical or drab and dreary. There was no 
middle ground. Clinical offices had high levels of illumina- 
tion, easy-to-clean shiny surfaces, and a lot of medical or 
dental instruments in view — clean and clinical. At the 
other end of the spectrum were offices with brown shag 
carpeting, residential pendant lights, nubby, earth-tone 
upholstery fabric that wouldn't show soil, and poorly 
styled wood furniture that appeared to have been res- 
cued from a Salvation Army truck. Dusty pothos plants in 
macrame hangers complete the picture of these dingy 
and unhygienic environments. 



I concluded that I would have to do my own empirical 
research to gather enough data on which to base my 
design work. I spent the better part of a year visiting hos- 
pitals, interviewing staff and patients, and observing how 
patients were handled. I wanted to see the facility through 
the patients' eyes. I also visited many physicians and den- 
tists and asked about their practices — what kinds of 
instruments they used; what size treatment room would 
be optimal; what kinds of changes would make their 
offices more efficient; and what critical adjacencies exist- 
ed between rooms or treatment areas. 

I documented my visits with photographs of confusing 
signage, waiting rooms furnished with Goodwill rejects, 
dismal lighting, corridors jammed with medical equip- 
ment, and procedure rooms that resembled Dr. Jekyll's 
laboratory. At the end of my research, I had accumulated 
over 2000 photos and reams of notes, which I analyzed, 
and, from this, I formulated my design philosophy. My 
dual majors, Psychology and Environmental Design, pro- 
vided a theoretical background with which to interpret the 
data. This database, combined with my current 30 years 
of experience designing hundreds of medical and dental 
offices, has resulted in this book. 

A person with no prior experience in healthcare design 
can study this book and become familiar not only with cur- 
rent economic and practice management issues, but also 
with medical and dental procedures, equipment associat- 
ed with each medical or dental specialty, room sizes, traf- 
fic flow, construction methods, codes, interior finishes, and 
more. I have attempted to synthesize my research and 
experience so that others will not have to follow such a 
laborious course of study in order to become proficient in 
a field that requires such highly specialized knowledge. 



IX 



Today, probably more than a thousand architects and 
designers across the country list healthcare as one of 
their specialties. In its infancy when I started out, the field 
has now reached maturity. No longer concerned with dis- 
covering the basic rules and principles, healthcare design 
specialists can devote themselves to refining what has 
been learned and to innovation. 

The first edition of this book was published in 1982 and 
featured exclusively my own work. However, the second 
edition (1 990) and the new third edition, in order to give a 
broader perspective, include examples of work by other 
practitioners, who are credited under each photo. I thank 
each of these architects, designers, and photographers 
for sharing their work. 

The third edition updates the book on digital technolo- 
gy — electronic medical records, digital imaging, digital 
diagnostic instruments, and networked communications 
— and how these impact the design of medical and den- 
tal offices. The milieu in which physicians and dentists 
practice — the impact of managed care, the Internet, the 
baby boomer generation, the age wave, the large number 
of uninsured Americans — is presented as a backdrop for 
understanding the pressures on the healthcare system 
and, also, implications for facility design. 

Expanded chapters include new medical specialties: 
reproductive enhancement (in vitro fertilization), pain 
management, breast care centers, LASIK eye surgery, 
and medical oncology. Nowhere have changes in tech- 
nology been more apparent than in dentistry and diag- 
nostic imaging. These and most other chapters have 
been totally rewritten. Nearly 100 new or revised space 
plans, totally revised space programs for all specialties, 
and 90 percent new photos of facilities and equipment 
have been added to all chapters, and the text has been 
rewritten to include new developments in medical and 
dental treatment and to familiarize readers with state-of- 
the-art medical and dental equipment. Fabrics and interi- 
or finishes representative of recent technological 
advances are introduced as well as ergonomically appro- 
priate furniture. The lighting chapter has been revised to 
acquaint readers with new types of lamps and fixtures 



and innovative solutions to enhance both aesthetics and 
function. 

A major change since the last edition of this book is 
the rigor of regulatory agency review of office-based 
surgery practices, far more stringent mandatory regula- 
tion (certification, licensing, and accreditation) of ambu- 
latory surgical centers, and interest by group practices 
and large managed-care organizations in seeking vol- 
untary accreditation from one or more national agencies 
as well as Medicare certification. Ambulatory-care 
enterprises such as a breast care center, urgent care, 
women's center, or radiation therapy that may physical- 
ly be located in a medical office building but are covered 
under the hospital's license, will most likely be subject to 
a JCAHO survey and accreditation. This book will help 
clarify the roles of these various agencies, explain which 
aspects of the regulations apply to the built environ- 
ment, and answer many questions that often arise when 
trying to understand compliance. I've also tried to clari- 
fy OSHA issues that affect design, which required wad- 
ing through several inches of "interpretive letters" to find 
those kernels that impacted safety of personnel and 
were within the province of design professionals as 
opposed to policies and procedures followed by staff to 
protect themselves. 

I offer special thanks to my colleagues, architect Bill 
Yeaple, Ph.D., for his invaluable assistance in research 
and in acquiring updated photos of equipment; and archi- 
tects Osia Orailoglu; Joost Bende, AIA; and Chris Shinall 
for their assistance in updating space plans; and to my 
executive assistant, Mary Anne Jones, for her extraordi- 
nary help and perseverance in preparing the manuscript. 
I would also like to thank the AIA Academy of Architecture 
for Health for providing me with an advance draft of the 
new Guidelines for Design and Construction of Hospital 
and Health Care Facilities, chapter on ambulatory care. 

On a final note, although the book attempts to familiar- 
ize readers with basic code information, codes vary geo- 
graphically and the architect or designer must check local 
and state codes, as well as the evolution of the 
Americans with Disabilities Act (ADA) legislation. 



x Preface 



Acknowledgments 



The author wishes to acknowledge Bill Rostenberg, FAIA, 
of the SmithGroup for his advice, expertise, and critique of 
the diagnostic imaging portion of this chapter. I am most 
grateful for his generosity of time and spirit. I am also 
appreciative of the expertise of Scott Jenkins whose 30 
years of experience planning diagnostic imaging equip- 
ment sites and providing technical assistance has been 
most helpful in pointing out what designers often overlook. 



The author thanks Lee Palmer, a biotechnology engi- 
neer with over 30 years' experience in the dental field as 
a space planner and equipment selection consultant, for 
his generosity of spirt and invaluable expertise in review- 
ing this chapter. Thanks also to architect T Michael 
Hadley for sharing his innovative work and to Dr. Larry 
Emmott, a passionate technology buff who writes a col- 
umn for Dental Products Report. 



XI 



Introduction: Changing Perspectives 



HEALTHCARE FINANCE 

Dramatic changes have occurred in the delivery of health- 
care since the first edition of this book when undiscounted 
fee-for-service reigned. The seminal event that kicked off a 
series of radical changes in the traditional fee structure 
began in 1984, with the federal government's prospective 
pricing program whereby Medicare and Medicaid reim- 
bursements were made on a fixed, flat-fee basis, rather 
than as a percentage of an individual physician's fee. 
Based upon a current list of 500 diagnosis-related groups 
(DRGs) of procedures, the physician/provider receives a 
flat fee, regardless of actual cost. Each DRG has a "weight" 
established for it based primarily on Medicare billing and 
cost data. Each weight reflects the relative cost, across all 
hospitals, of treating cases classified in that DRG. Since 
Medicare and Medicaid comprise approximately 33 per- 
cent of the national healthcare budget, hospitals and 
physicians have been forced to take a hard look at ways to 
reduce costs. Following the lead of the federal govern- 
ment, some states also have initiated prospective pricing 
programs, and insurance companies have followed suit, 
issuing guidelines and directives, and making physicians 
feel that third-party payers, rather than they, are managing 
their patients' care. 

During the 1990s, the demands of investors increas- 
ingly influenced the delivery of healthcare services as a 
growing number of hospitals, home healthcare services, 
skilled nursing facilities, and HMOs (health maintenance 
organizations) became for-profit entities, publicly traded 
on Wall Street. Investor ownership profoundly influenced 
the "product" of healthcare by intensifying competition, 
creating a focus on cost containment, reducing the auton- 
omy of physicians, and, ultimately, reducing healthcare 
services to a commodity. But by 1997, healthcare stocks 
were performing poorly because cost containment and 



competition had reduced profit margins and Medicare and 
Medicaid had made serious budget cuts. Then came the 
scandals leading to the collapse of two of the most cele- 
brated companies — Columbia/HCA and Oxford Health 
Plans. 

Just when healthcare finance seemed as if it couldn't 
get any worse, it did. The Balanced Budget Act of 1997 
required that Medicare expenditures be cut by $115 bil- 
lion over a period of five years, placing enormous pres- 
sure on hospitals to reduce costs. 

On the insurance front, the biggest change over the 
past five years has been the growth of HMO enrollment 
from 50.6 million Americans in 1995 to 80.9 million in 
2000; however, this trend is slowing. 1 A more detailed dis- 
cussion of HMOs and market penetration can be found in 
Chapter 6, and an excellent financial summary of the 
American healthcare system in the 1990s is available in 
The New England Journal of Medicine. 2 According to this 
article, in 1997, only about one-third of HMOs recorded a 
profit, since they faced considerable competition from 
each other and from physician-owned health plans and 
those sponsored by hospitals. Additionally, consumer dis- 
satisfaction with restrictions on care and a rash of bad 
press has led to a proliferation of managed care alterna- 
tives, and in Washington, patients' rights legislation looks 
as if it may pass in the 2001 Congress. 

Although some states have remained relatively unaf- 
fected by managed care and physicians in those states 
are doing well with discounted fee-for-service reimburse- 
ment, physicians in states like California, Rhode Island, 
Delaware, Hawaii, and Pennsylvania — those with the 



1 Russell C. Coile, Jr., Futurescan 2001, Health Administration Press, Society for 
Healthcare Strategy and Market Development, Chicago, 2001, p. 15. 

2 Robert Kuttner, 1 999. "Health Policy Report: The American Healthcare System — 
Wall Street and Healthcare," New England Journal of Medicine 340(8): 664-668. 



XIII 



highest managed-care penetration 3 — have seen serious 
erosion of their income. This has led physicians into 
entrepreneurial niche enterprises, such as ambulatory 
surgery ventures, oncology care, cardiac care, and free- 
standing radiology centers, in competition with hospitals. 
Today, medical insurance is complicated and has 
become a battleground wherein healthcare providers, 
consumers, employers, and insurance companies are 
each trying to retain control of their respective interests. 
Whether healthcare will ever be "reformed" to include the 
uninsured and to fulfill the original promise of managed 
care — to provide closely integrated services, eliminating 
waste, and enhancing clinical outcomes- remains 
unclear. The ever-shifting sands of healthcare politics 
reveal, however, a certain sensitivity to public opinion. 
Recent announcements by Blue Cross and other large 
payers promise to allow physicians to make the final deci- 
sion on treatments for their patients. And some have fur- 
ther proposed to reward physicians with bonuses for 
receiving high patient satisfaction scores as opposed to 
rewarding them for restricting access and containing 
costs. As managed care loses popularity, a "consumer 
choice" model is emerging in which hospitals are com- 
peting on new facilities and amenities. (Never underesti- 
mate the power of the American consumer.) 

REGULATORY ISSUES AFFECTING PHYSICIANS 

A number of recent regulatory issues will significantly 
affect physicians. 

Ambulatory Payment Classifications (APCs) 

Medicare's prospective payment system has hit ambula- 
tory care. Similar to DRGs, the APC classifications fall 
into three categories: surgical, medical, and ancillary. 
Therapies such as physical therapy, speech, occupation- 
al therapy and also laboratory work are excluded and are 

3 IHS® Health Group: 2000 Managed Care Profile Map. 



paid on a fee schedule, as mammography screening and 
durable medical equipment will be. Imposed by HCFA 
(Healthcare Financing Administration) in August 2000, 
APCs will affect ambulatory surgery, which has become a 
battleground between physicians and hospitals. Seventy 
percent of all surgery is done in an outpatient setting. 4 
The less complex (and more lucrative) cases are 
siphoned off by physicians to be performed in an ambu- 
latory surgical center, while the hospital is left with com- 
plex cases and declining reimbursement. 



HIPAA 

The Health Insurance Portability and Accountability Act of 
1 996 will continue to result in many changes and costs for 
both physicians and dentists. 5 HIPAA is a mandate from 
the federal government to automate health-related finan- 
cial and clinical data to protect patient privacy. In coming 
years, this will result in significant cost for software, com- 
pliant hardware, employee training, personnel security 
policies, considerable documentation, and monitoring of 
compliance. The use of a single HIPAA-defined adminis- 
trative standard for electronic transactions, such as 
claims processing and verification of eligibility, is one of 
the goals. Although HIPAA refers only to electronic data, 
one wonders how, or if, this will also affect paper records 
storage, commonly accessible even to janitorial staff, in 
open rooms and/or unlocked chart file cabinets. 



FORCES SHAPING HEALTHCARE 

Institute of Medicine (IOM) Report 

One of the hottest issues in healthcare in 2001 was the 
IOM report, To Err Is Human: Building a Safer Health 



A Russ Coile's Health Trends, Aspen Publishers, Inc., Frederick, Maryland, 2000, 
12(9): 2. 

5 Russ Coile's Health Trends, Aspen Publishers, Inc., Frederick, Maryland, 2000, 
12(4): 3. 



xiv Introduction 






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Home telemedicine monitoring, Aviva™ central station. (Photo courtesy: American 
TeleCare, Eden Prairie, MN.) 



Home telemedicine monitoring, Aviva™ patient station. [Photo courtesy: American TeleCare, 
Eden Prairie, MN.) 



System, which was followed by Crossing the Quality 
Chasm. The IOM is a private, nonprofit institution that 
provides health policy advice under a congressional char- 
ter granted to the National Academy of Sciences. These 
two reports have placed medical errors on every 
provider's radar screen based upon the assertion that 
medical errors are probably the eighth leading cause of 
death in the United States — more than motor vehicle 
accidents, breast cancer, or AIDS. 6 Healthcare repre- 
sents more than half of the preventable accidents. 
Medical informatics and the avoidance of handwritten 
physicians' orders will solve some of these problems, as 
will electronic medical records, making the chart instantly 
available at any location, providing access to information 
about patients' allergies, notifying the clinical team about 
negative drug interactions, and flagging dosages that 

6 The National Academy of Sciences "NEWS," March, 2001 (www.news@nas.edu). 



exceed standards. Clinical pathways for treatment of var- 
ious illnesses are expected to weed out practices with 
poor clinical outcomes. 

Telemedicine 

According to Kirby Vosburgh, Associate Director of CIMIT 
(Center for the Integration of Medicine and Innovative 
Technology in Boston), healthcare will be moving into the 
home, changing "house calls to mouse calls." 7 Internet- 
enabled medicine will allow patients and providers to com- 
municate in cyberspace (see Figures 1 and 2), listening to 
a patient's heart or lungs, and monitoring blood pressure 



7 Lecture by Kirby Vosburgh, Ph.D., "The Electronic Outpatient/Home 
Environment — from House Calls to Mouse Calls," (Vancouver, British Columbia, 
October, 2000, "Beyond 2000: An International Conference on Architecture for 
Health." 



Introduction xv 



via computer. Telemedicine is especially useful for clinical 
consultations with physicians who are located in rural 
areas. This is expected to reduce the number of office vis- 
its and to help manage chronic illnesses, such as hyper- 
tension, and the number of acute complications that result 
from poor management of these conditions. Payment for 
"televisits" is expected within five years, and 50 percent of 
physicians will treat patients on-line, according to a survey 
by the American Medical Association. 



Medical Informatics 

The use of information systems in running a medical 
practice and managing patient care makes a vast store of 
clinical data instantly available to physicians. An aggre- 
gate database of millions of clinical encounters can be 
accessed with powerful software programs that will even 
run on a palm-top PC. Currently, patients with identical 
conditions may receive radically different treatments from 
different providers, whereas the use of a prognosis "cal- 
culator" enables physicians to quantify the advantages 
and disadvantages of various clinical strategies, to review 
research findings, and to calculate drug dosages while 
the patient is still in the exam room (Figures 3-29a and b). 
Another aspect of medical informatics is the computer- 
based provider order entry (CPOE), which is expected to 
greatly reduce errors due to illegibility. 



The Experience Economy 

A new approach to marketing underscores the value of 
creating an experience that engages customers in a per- 
sonal way. 8 Staged experiences create memorable and 
lasting impressions that can bond customers — in this 
case, patients — to a specific provider. As an example, 
Starbucks has effectively demonstrated that a basic com- 
modity like a cup of coffee can be presented in an envi- 



8 B. Joseph Pine II and James Gilmore, The Experience Economy, Harvard 
Business School Press, Boston, 2000. 



ronment that elevates the experience in such a way that 
customers will pay considerably more for the product than 
they would at the corner diner. Similarly, experiences can 
be designed and scripted \r\ the healthcare setting to help 
differentiate a provider from competitors and to ensure a 
level of customer service that exceeds expectations 
(including Starbucks cafes that are now being installed in 
some hospital lobbies). Baby Boomers, as a consumer 
group, have been characterized as being finicky and dis- 
criminating, and willing to spend the time to evaluate a 
variety of goods and services before making a commit- 
ment. In the new economy, Baby Boomers will fuel the 
demand for memorable experiences and will often be will- 
ing to pay more for these services. 



The New Consumer 

Much has been written about the new consumer: a more 
well-educated comparison shopper, empowered by the 
Internet, with the analytical ability to review research and 
form an opinion about treatment options. This group has 
grown from 25 percent of the population 20 years ago to 
45 percent today. By 2005, they will constitute 52 percent 
of the population. 9 

Universal Beliefs 

According to a study by Yankelovich Research, the new 
consumer has three universal beliefs: 10 

• Doctors can be wrong. 

• People know their own bodies best; self-reliance is wise. 

• Quality is important, and consumers want the best for 
less; value is being redefined. 

Patients are realizing, largely due to their personal expe- 
riences with managed care — but also influenced by the 



institute for the Future Executive Summary: The New Healthcare Consumer 

(MenloPark, CA: 1998): 1. 

10 A report delivered at Healthcare Forum Summit, 1998. 



xvi Introduction 



media — that cost containment pressures and the com- 
plexities of the healthcare system leave them vulnerable 
to being ignored, being denied treatment, or being 
exposed to medical error unless they aggressively take 
responsibility for educating themselves and "managing" 
their own healthcare. These empowered consumers are a 
new factor, identified in a Price Waterhouse Coopers fore- 
cast of the healthcare industry (with projections to the 
year 2010) as the most important force behind change. 11 
It, and other similar forecasts characterize Baby Boomers 
as "adversarial, fickle, and impatient" and point out that 
providers are "not prepared to serve the highly differenti- 
ated expectations of these strong-willed and knowledge- 
able individuals." 12 

Baby Boomers Empowered by the Internet 

A major change agent has been the explosion of 
Internet sites, giving patients access to self-care infor- 
mation, journal articles, and chat rooms associated with 
specific diseases 24 hours a day, seven days a week. 
Consumers with the motivation and education to do 
this type of research and the ability to understand what 
they are reading have been arriving at their doctors' 
offices prepared to discuss potential diagnoses and 
treatment options. Some physicians have not been pre- 
pared for, nor have they welcomed, this sort of colle- 
giality and "partnership" with patients, and they have 
responded in a variety of ways that express how 
uncomfortable they are when their authority is being 
challenged. But if the research published in the past few 
years is any indication, this trend will accelerate, not 
diminish. From the physician's perspective, valuable 
examination time can be squandered by having to sort 
through a stack of studies that may or may not be rele- 
vant to the patient's condition. Nevertheless, the new 
consumer's desire to "take charge" and to play a proac- 
tive role seems to be a force that physicians will have to 
contend with. 



Responding to the Pace of Change 

Healthcare providers will need to develop strategies to 
meet consumer demands. 13 These include the following: 

• More choices — of health plans, open provider net- 
works, treatment options to help maintain market 
share. 

• More control — the new consumers are more active 
and participatory in their healthcare and are interested 
in self-care. 

• Superior customer service, being consumer-friendly 

• Branding — a way of differentiating services with 
direct-to-consumer marketing, offering an ombuds- 
man, and perhaps offering complementary and alter- 
native therapies 

• Access to information — the new consumers devour 
information and become frustrated when access is lim- 
ited. 

Barriers to Consumer-Focused Healthcare 

The transformation of the healthcare system to meet the 
demands of the new consumer may be slowed by third- 
party payers as mediators between the physician/patient 
interaction; the difficulty of measuring and comparing the 
quality and price of health services; and the gap in infor- 
mation and authority between consumers and 
providers/physicians who have attended medical school 
and are more knowledgeable. 14 

The Baby Boomer Bulge 

The majority of Baby Boomers will not reach age 65 until 
2010. As that population ages, it is expected to challenge 
and change society's view of aging as it has changed 
other societal structures. The increase in the numbers of 
persons who have attended college will impact the 
healthcare system sometime after 2005 as income 



11 "SMG Market Letter," (Chicago, IL: SMG Marketing Group Inc., 2000), 14(1): 1. 
12 lbid:1. 



13 Institute for the Future Executive Summary: The New Healthcare Consumer 

(Menlo Park, CA: 1998): 1. 

14 lbid:1-2. 



Introduction xvii 



inequality declines slightly. (Research has shown that 
health status increases proportionately with educational 
level.) The current 74 percent Caucasian population will 
decrease to 64 percent by 2010, with Asians comprising 
5 percent, African-Americans 12 percent and, in certain 
western states, Latinos approximately 15 percent of the 
population, according to forecasts. 15 

Tiered access to healthcare will be reflected by the top 
tier, comprised of empowered patients with discretionary 
income, education, and the ability to use technology like 
the Internet; the next tier, who have access to health 
insurance but have little or no choice of health plans (this 
includes those who are temporarily employed and early 
retirees who have less or no discretionary income); and 
the third tier, comprised of the uninsured and those on 
Medicaid, who have no access to technology and no abil- 
ity to participate in decisions about their health or treat- 
ment options. 16 



by time and motion studies, thereby reducing a valued 
patient/physician relationship to a commodity. 

As we enter the twenty-first century, physicians are 
being faced with seismic changes in a system that has 
served them well for a hundred years: the shift to elec- 
tronic medical records, telemedicine, and medical infor- 
matics in all its forms; digital imaging; and the erosion of 
authority by virtue of vast medical data banks now avail- 
able to consumers, not in a medical library, but in their 
own homes. These are tremendous cultural changes for 
midcareer physicians. Recent medical school graduates, 
on the other hand, will be far more comfortable in this new 
environment. 



ABOUT THIS BOOK 
A Reader's Guide 



Disconnect Between Values and 
Economic Reality 

The sense of mission and the core values that attract 
many to a career in healthcare has been jeopardized by 
the notion that economic performance is more important 
than properly caring for patients. The "business of medi- 
cine" is creating a corrosive environment for doctors, 
nurses, and patients. 

According to noted ethicist Emily Friedman, every 
healthcare decision is both a business decision and a val- 
ues decision. The last decade of the twentieth century 
has been a tug-of-war between those two polar forces. 
Some have pondered whether, 1 or 1 5 years from now, 
when we look back on the decade of the 1990s, policy- 
makers will feel any shame about having turned physi- 
cians into hamsters who are running faster and faster on 
a wheel to only stay in place, measuring their production 



^ s lnstitute for the Future Executive Summary: The New Battlegrounds (Menlo 

Park, CA: 1998): 2. 

16 lbid:3. 



For medical practices, it is essential that you read Chapter 
3 first, as it is the foundation for all the specialty practices 
that follow. Chapters on sports medicine, physical therapy, 
diagnostic imaging, and ambulatory surgical centers are 
relatively self-contained. The dental chapter can be read 
independently of the medical chapters, although there are 
cross-references to other chapters on lighting, construc- 
tion methods, furniture, interior finishes, and color. 



A Word of Advice to Providers 

Physicians and dentists should not lease office space 
prior to having a space planner prepare a program (list of 
rooms, sizes, and critical adjacencies) and a summary of 
total square footage required. This would be analogous to 
shopping for a suit of clothes without knowing what size 
one wears. In fact, if you are considering two or three 
alternative spaces, the fee invested in a program and 
schematic space plan will pay huge rewards in demon- 
strating which space most appropriately lends itself to 
your practice's needs. In fact, a smaller space with spe- 
cific dimensions or a specific configuration may accom- 



xviii Introduction 



modate you better than a larger one. Signing a ten-year- 
lease on an inefficient, awkward space can hamper your 
practice and be costly in more ways than one. 



The Heterogeneous Nature 
of the Clinical Office 

This book addresses a wide variety of clinical offices, 
from solo practitioners of primary care with a single 
employee in the front office to large group practices with 
dozens of physicians, medical assistants, and support 
staff. The latter category includes multispecialty group 
practices, specialists who may be accessed by referral 
only, and hospital-based clinics. But, according to a 
leader in the redesign of clinical practice, "despite the het- 
erogeneity of the clinical office as a place of work, almost 
all its forms share in common one property: historical sta- 
bility of design in the face of enormous changes in both 



the environment and agenda of healthcare." 17 Hopefully, 
the information and resources introduced in this book will 
stimulate innovation and encourage providers to consider 
new possibilities, in addition to explaining the basic prin- 
ciples of medical space planning. 



Meeting the Challenges Ahead 

As physicians regroup to meet the challenges ahead, 
competent medical space planners will be needed, and 
they will be expected to be familiar with new technology, 
the types of medical procedures being performed, and 
the latest techniques and equipment. To that end, this 
book will be an invaluable guide. 



17 Charles Kilo, M.D., MPH, Idealized Design of Clinical Office Practices, 
Conference Proceedings, Symposium on Healthcare Design, San Francisco, 
1998,458. 



Introduction xix 



CHAPTER I 



Psychology: 

Implications for Healthcare Design 



OVERVIEW 

A visit to the physician or dentist traumatizes many people. 
The basis for the fear, even more than lack of familiarity with 
procedures and a feeling of helplessness, may stem from 
the perception of invasion of one's personal space. 

Touch and proximity can be comforting elements in 
other cultures, whereas Americans maintain larger territo- 
rial boundaries. For example, an American may maintain 
an imaginary barrier 24 inches in front of him or her as a 
safe conversational distance for strangers, while a person 
from the Middle East may reduce that safe boundary to 12 
inches. 

During a medical or dental examination, a person is most 
vulnerable, both emotionally and physically. One's territori- 
al limits are invaded by strangers who poke, probe, and 
prod. And when the examination demands that the patient 
be naked, clad only in a gown, even the barrier of clothing 
ceases to protect. Is it any wonder that a visit to the dentist 
or physician can intimidate even the most stouthearted 
among us? How, then, can practitioners breakthrough this 
barrier to examine and treat patients without arousing fear 
and anxiety? 

First, the patient must perceive the positive aspects of 
the care he or she is receiving through an understanding of 
the procedures and how they will enhance his or her enjoy- 
ment of life. The relief of pain and the prevention of disease 
are joys in themselves. Second, the diagnostic and thera- 
peutic milieu must promote health rather than aggravate ill- 
ness and cause anxiety. The environment must be clean, 



cheerful, and nonthreatening, with contemporary furnish- 
ings, pleasing colors, interesting textures, and compatible 
works of art. The staff should be neatly groomed, well 
trained, friendly, and interested in the patients' well-being. 



PATIENT SATISFACTION 

Patient satisfaction is the new buzzword. It's the difference 
between providing what a patient needs and what a patient 
wants. It is important not only to satisfy clinical needs, but 
also to meet psychological expectations, which includes 
comfort and compassionate care. It is interesting to note 
that the two preceding sentences appeared in the last edi- 
tion of this book written 12 years ago and they are still cur- 
rent. The fact that patient satisfaction is still regarded as a 
"new" trend demonstrates that it is still a work in progress 
and has not achieved enough critical mass to settle in as 
one of the basic components of patient care. Yet far more 
research has been done in the past five years to more 
closely define patient and customer satisfaction. The Picker 
Institute (www.picker.org) and the Center for Health Design 
(www.healthdesign.org) jointly sponsored research that 
culminated in a document published December 1997, 
Consumer Perceptions of the Healthcare Environment: An 
Investigation to Determine What Matters, a copy of which 
can be obtained from either organization. An effective 
video is also available. The Center for Health Design has 
also worked closely with JCAHO (Joint Commission on 
Accreditation of Healthcare Organizations) to develop stan- 



dards to assess the built environment relative to what 
matters most to patients in order to reduce anxiety and 
provide a more patient-centered environment. 

Principal components of patient satisfaction are a warm 
and caring staff, comfortable surroundings, and the ability 
of patients and visitors to easily find their way around the 
medical center without getting lost. Convenience and ease 
of access are critically important as is privacy. Why priva- 
cy has only this past year hit the radar screens of regula- 
tory agencies that create standards and inspect healthcare 
facilities is not entirely clear as it has always been impor- 
tant to patients. Of course, the federal HIPAA (Health 
Insurance Portability and Accountability Act of 1996) leg- 
islation kicked it into high gear. It's a fact that change 
occurs at glacial speed in the healthcare industry, which is 
both good and bad. It's good when evaluating clinical pro- 
cedures or pharmaceutical agents that may threaten a 
patient's life, but it's bad when something as simple as pro- 
viding privacy for someone who is registering for surgery 
requires, literally, an act of Congress. 



CONSUMER PERCEPTIONS OF THE 
HEALTHCARE ENVIRONMENT 

In the aforementioned research sponsored by the Picker 
Institute and the Center for Health Design, the following 
issues were raised by consumers with respect to expec- 
tations in the ambulatory-care setting.* According to this 
report, in ambulatory care consumers want a physical 
environment that: 

Facilitates Connection to Staff. Patients want to be noticed 
upon arrival and not be overlooked when they are called 
for their appointment. 

Is Conducive to Well-Being. Patients want creature com- 
forts to keep them from becoming bored or anxious and 



'Consumer Perceptions of the Healthcare Environment: An Investigation to 
Determine What Matters, Lafayette, California, Center for Health Design and 
Picker Institute, Boston, 1998, pp. 10-13. 



consideration regarding room temperature, color, lighting, 
and avoidance of environmental stressors such as noise. 

Is Convenient and Accessible. Patients want to get in and 
out of the clinic as fast as possible. Ease of wayfinding 
was highly valued. 

Is Confidential and Private. Patients want confidentiality 
and privacy especially in the waiting room and during the 
clinical encounter. Patients do not want to overhear confi- 
dential information about other patients, nor do they want 
to be overheard. 

Is Caring for the Family. Patients want play areas for their 
children and accommodation for family who accompany 
them into exam rooms or for diagnostic treatments. 

Is Considerate of People's Impairments. Patients want 
seating and signage that accommodates the elderly and 
those with various impairments. They also requested con- 
sideration of those who arrive at the clinic feeling quite ill 
who would like a quiet place where they may be able to 
lie down. 

Is Close to Nature. Patients highly value views of gar- 
dens, sky, natural light, as well as contact with nature in 
terms of aquariums, indoor plants, and water elements. 



THE NEW CONSUMERISM 

The rise of consumerism and the Internet have radically 
changed patient/physician relationships. There was a 
time when people never dared to question a physician's 
diagnosis or recommendations for treatment. Physicians 
and other healthcare professionals were placed on a 
pedestal, and even malpractice suits were infrequent. 
Sociologists attribute this loss of innocence to the 
Vietnam War, the Watergate scandal, the dumping of 
toxic waste, and other events that have caused some to 
question whether those in authority actually have our 
well-being in mind. Added to this are the efforts of people 



2 Psychology: Implications for Healthcare Design 



like Ralph Nader, who educated consumers to examine 
critically the safety of products and practices commonly in 
use. The result is a new group of consumers who focus 
on wellness, who put responsibility for health in their own 
hands, who play an active role in keeping themselves fit, 
and who shop for healthcare services with a critical eye. 
The powerful explosion of self-care Web sites on the 
Internet, coupled with unprecedented access to health 
data and medical research from one's home "24/7" has 
dramatically changed the patient/physician interface. 

Shopping for healthcare services began in the 1 980s. 
Prior to this, people visited the family doctor with whom 
they had grown up, or they selected a practitioner in the 
neighborhood. However, with the mobility that character- 
izes our society, people move frequently, and long-term 
relationships with healthcare providers are often not pos- 
sible. Managed care has also impacted the "sacred" 
physician/patient relationship: physicians may be denied 
access to the care they think is best for an individual 
patient and patients may be forced to change physicians 
when they change employment or when health mainte- 
nance organization (HMO) physician panels change. 
Interest in holistic medicine and the proliferation of public 
information regarding the prevention of disease have also 
fueled the consumer-driven market. 

One would expect a consumer-driven market to 
spawn competition among healthcare providers who, in 
the context of this book, are physicians and dentists, not 
hospitals. Dentists have historically been savvy about 
marketing and sensitive to consumer issues and there 
was a time when physicians had more impetus to attend 
to such concerns. Today, however, reimbursement for 
medical care has been impacted so dramatically by 
managed care and HCFA (Health Care Financing 
Administration) that just keeping the door open and the 
lights on can be a challenge. And, to be sure, there are 
large groups of patients who do not have the luxury of 
"shopping" for healthcare services: they may be unin- 
sured and happy to receive any care at all. That's the 
reality. Despite this, the issues raised in this chapter are 
important and should be considered when remodeling or 
planning new offices. 



FIRST IMPRESSIONS COUNT 

Once the patient walks into the office, the waiting room 
should establish immediate rapport and put the patient at 
ease. First impressions are very important. Out-of-date 
furniture, worn upholstery, and grimy spots on walls may 
give the patient a message that the doctor does not care 
about patient comfort, or that he or she is reluctant to 
replace things when they wear out. No doubt, it's more a 
matter of heavy workloads and the fact that physicians 
rarely walk through their own waiting rooms. But percep- 
tion is reality. It may subliminally suggest that the doctor 
is outdated on medical matters as well, which can lead to 
a lack of confidence and breed anxiety in the patient. 

Subliminal Cues. There is no substitute for live green 
plants in a waiting room. Plastic plants suggest that live 
plants probably could not survive the environment, and 
the patient may fare no better. Healthy, lustrous greenery, 
on the other hand, promotes feelings of well-being. 

A poorly illuminated waiting room not only makes it dif- 
ficult to read, but subliminally suggests to patients that 
the staff is trying to hide something — perhaps poor 
housekeeping. It is surprising how often one finds badly 
soiled carpet and upholstery. Professional cleaning of 
these items should be routinely scheduled. Burned-out 
light bulbs are the ultimate insult, indicating a consum- 
mate inattention to detail. 

A closed, sliding glass window with a buzzer for serv- 
ice tells patients that they are not really welcome — that 
they are intruding on the staff's privacy. The receptionist 
should always be in view of patients and accessible to 
them. 



WAITING: A FRUSTRATING 
INCONVENIENCE 

Waiting, unhappily, is one of the frustrations that often 
accompanies a visit to the doctor. Patients who are in 
pain or who are alarmed about an undiagnosed illness 
will accept waiting, realizing that doctors cannot always 



Waiting: A Frustrating Inconvenience 3 



schedule appointments accurately. Well patients, howev- 
er, such as those in a screening facility, have a different 
attitude and are not willing to accept discomfort or incon- 
venience without registering complaints. 

Few wait with pleasure. In fact, waiting tends to con- 
centrate one's attention on the details of the surround- 
ings, making the presence or lack of good interior design 
more noticeable. Burned-out light bulbs, waxy and dusty 
plastic plants, and the crooked magazine rack become 
exaggerated irritants. 

Many people visit a physician or dentist during their 
work day. Excessive waiting leads to anxiety and hostility, 
with worries about time away from the office and being 
late for meetings. An emergency at the hospital or the 
delivery of a baby are situations that people will forgive. 
They understand medical emergencies. But physicians 
who make a continual practice of overbooking are, per- 
haps without realizing it, offending their patients. 



Research About Waiting 

A study designed to investigate the effect of waiting time 
in the ambulatory setting revealed the following*: 

• Time spent in the waiting room itself was not as impor- 
tant as total time spent waiting to receive care. 

• Patients who were occupied while in the waiting room 
were less likely to be dissatisfied. 

• A long wait in the treatment room engendered dissat- 
isfaction with the clinicians. 

• A short time in the waiting room raising expectations 
for a quick visit, followed by a lengthy wait in the treat- 
ment room, resulted in feelings of anger and resent- 
ment. 



*K. H. Dansky, 1997. "Patient Satisfaction with Ambulatory Healthcare Services: 
Waiting Time and Filling Time." Hospital & Health Services Administration 
42(2):165-177. 



Unoccupied time while waiting was perceived as 
longer, suggesting that strategies to fill time (watching 
a video, working a jigsaw puzzle, studying an aquari- 
um, searching the Internet) are worthwhile. 

Informing patients how long they will have to wait 
increased patient satisfaction. 



Seating Arrangements 

Americans, in particular, do not like to be in close prox- 
imity to strangers. Middle Eastern and Latin cultures, by 
contrast, encourage closeness and touching. In the Arab 
world, olfaction, as expressed by breathing in the face of 
a friend, is considered a necessary part of social grace. 
To deny a friend of the smell of one's breath is a cause of 
shame. Middle Easterners and Latinos will huddle 
together much more closely than will Americans in a 
crowd. 

Thus, seating arrangements in a waiting room 
designed for Americans should not force strangers to sit 
together — this only intensifies the stress of visiting the 
physician or dentist. Yet, in deference to the ethnic diver- 
sity that characterizes the American population, flexibility 
should be built in to allow waiting in family groups as well 
as offer seating that minimizes interaction with strangers, 
since both options may alleviate stress for the widest 
number of individuals. Individual chairs should be provid- 
ed and arranged so that strangers do not have to face 
one another with a distance of less than 8 feet between 
them. Chairs should be placed against walls or in config- 
urations that offer a degree of security, so that seated per- 
sons do not feel they are in jeopardy of being approached 
from behind. Careful planning in this regard will assure 
patient comfort. 



Cultural Differences 

If the medical office or clinic serves an ethnic population, 
it is important to research how that group uses space. 



4 Psychology: Implications for Healthcare Design 



Some cultural groups, for example, tend to bring many 
relatives when one family member has to visit the doctor. 
Perhaps this is due to the need for emotional support pro- 
vided by the presence of the family. People who do not 
speak English well or those from rural areas might easily 
become intimidated by modern technology. Books by 
Robert Summer and Edward T. Hall are excellent 
resources on the cultural use of space. 



PERCEIVED STATUS DIFFERENCE 

One of the reasons patients feel intimidated may be due 
to the perceived status difference between the physician 
or technician and themselves. The patient sits in a pow- 
erless position while being acted upon by others. Feelings 
of helplessness are accelerated when physicians do not 
establish rapport and make eye contact with patients. 
This can be facilitated by the layout of the examination 
room and the way it is furnished. 



Body Language Indicates Stress 

A number of research studies have explored the subject 
of physician/patient rapport and the importance of main- 
taining it during the clinical encounter. The patient's body 
language may indicate when the patient is uncomfortable 
with the physician, dentist, or technician. Averted eyes — 
looking away from the doctor — is one sign. Body posi- 
tioned away from the doctor is another. Stereotyped 
behavior (tapping toes, shaking a leg, or rocking) is 
another. At these signs, the doctor must reestablish con- 
tact with the patient to break the "distance" barrier. 
Touching the patient's hand or arm and asking if he or she 
is okay is both friendly and reassuring. Interestingly, sev- 
eral studies have demonstrated that if the physician asks 
the patient's opinion about the cause of the illness, rap- 
port increases considerably and it also provides some 
fairly accurate clues to the source of the problem that the 
physician might otherwise not discover. 



Preserving Patients' Dignity 

Another example of patient discomfort may occur when a 
radiologist or tech speaks from a remote control room to 
a gowned patient splayed on the X-ray table. Every effort 
should be made to treat the patient as an equal, to 
explain each step of a medical or dental procedure, to 
make the patient a partner in his or her treatment, and to 
allow the patient as much dignity as possible during what 
can best be described as humiliating medical examina- 
tions such as gastrointestinal X-ray studies or sigmoido- 
scopies. An individual's most private bodily functions are 
scrutinized by strangers, causing great psychological 
stress. 



SEEING THE DOCTOR AS A PERSON 

The consultation room (and occasionally, but rarely, the 
waiting room) may contain the doctor's personal memo- 
rabilia. Such items help the patient to see the doctor as a 
person with a family, hobbies, and interests outside of 
medicine. This reassures the patient, establishes rapport, 
and reduces the intimidation factor. In other than a solo 
practice (one physician), however, personal items should 
be kept out of the waiting room. 



Style of Furnishings Should 
Not Be Trendy 

There is considerable opportunity for the doctor to 
express his or her personality and style preferences in 
furniture and interior design. Indeed, for obstetricians, 
gynecologists, plastic surgeons, and pediatricians, the 
sky is the limit. But most physicians, surgeons in particu- 
lar, must carefully select furniture that will convey a solid, 
conservative image. Patients need to feel that their sur- 
geon is not impulsive — that he or she is a serious person 
not subject to frivolities and trendy decor. This is true for 
oral surgeons as well. General dentists who practice solo 
have more leeway in expressing personal interests (such 



Seeing the Doctor as a Person 5 



as sailing or mountain climbing) with office decor than 
those who practice in a group. 

Even if patients are not consciously aware of the mes- 
sage they are getting from the office interior design, they 
are subconsciously reading it. The body language of the 
office environment tells patients things that might sub- 
consciously undermine their confidence in the physician 
or dentist. Confidence can be reinforced through attention 
to patients' comfort. 



Although patients sometimes abuse nice furnishings by 
putting their feet on chairs or placing gum on the uphol- 
stery, unfortunately, that's the price that must be paid to 
make patients feel comfortable. The replacement factor 
should be built into the office overhead. The fact is, most 
patients do not abuse the pleasant surroundings provided 
for them, so why make the many suffer for the transgres- 
sions of the few? The psychological benefits of an office 
designed to serve patients far outweighs any drawbacks. 



6 Psychology: Implications for Healthcare Design 



CHAPTER 2 

General Parameters of Medical Space Planning 



BUILDING SHELL DESIGN 

Efficient medical offices begin with an intelligently designed 
building shell. All too often, medical office buildings (MOBs) 
are planned by designers or architects who are unfamiliar 
with the special requirements of medical tenants; thus, the 
structure of the building does not lend itself to an efficient 
layout of suites. Structural column locations, stair place- 
ment, elevators, electrical room, mechanical shafts, public 
restrooms (if provided), and window modules either impede 
of facilitate layout of individual suites. 

Other factors that influence the design of an MOB are 
the shape and size of the site, the specific requirements of 
a particular tenant or client, a beautiful view, or the archi- 
tect's desire to impose a unique design on the project. All 
of these factors have to be weighed and balanced along 
with applicable codes, zoning restrictions, and the client's 
budget. A building that is completely functional and effi- 
cient, but totally insensitive to aesthetics may not rent as 
quickly as the owners may wish. But an MOB designed pri- 
marily for aesthetic merit, with only secondary concern for 
internal planning efficiency, will also be difficult to lease. 



Floor Area Efficiency 

To begin with, an MOB should contain at least 12,000 
square feet of rentable space per floor in order to accom- 
modate suites of varying sizes and configurations as well as 
to increase the efficiency of stairs and elevators. Larger 
buildings often have 20,000 square feet per floor. The ele- 
vator, mechanical equipment room, electrical room, and 
public restrooms can be placed in the core with rental space 
wrapped around the perimeter (Figures 2-1 and 2-2) or the 



services may be located at the ends of a double-loaded 
public corridor (Figure 2-4). Figure 2-1 gives 80 percent 
rentable space and Figure 2-3 gives 89 percent rentable 
space, but it must be noted that Figure 2-1 includes rest- 
rooms. Medical buildings usually are designed to an 85 per- 
cent efficiency, but architectural features such as an atrium 
or a large lobby can reduce the efficiency to 80 percent. 

The core factor is 12 percent in Figure 2-2, reflecting the 
gain in efficiency due to the large floor plate. The building 
shell in Figure 2-2 is designed to accommodate large 
users on the 60-foot-bay-depth side. If the building is 
leased to smaller tenants, public corridors penetrating the 
60-foot depth may have to be added, thereby reducing 
somewhat the potential rentable area. 

Special attention must be paid to locating stairwells when 
one tenant intends to lease an entire floor or half a floor. In 
such case, the public exit stairwell may fall within an individ- 
ual suite — a nonpublic space. One way to handle this is to 
provide a third stair in the center of the building so that, even 
if one tenant takes half a floor, two stairs remain accessible 
for tenants on the other half of the floor (Figure 2-4). 

Figure 2-2 shows a layout with one stair set in, to allow a 
52-foot bay depth between it and the end of the building, so 
that a large suite can run across the end of the building either 
at the 52-foot depth or at a 32-foot depth utilizing a 20-foot 
"allowable" dead-end corridor, extending from the stairwell. 
One must remember, however, when locating a suite across 
the end of a building: If the occupancy load is high enough, 
two exits may be required, with a separation equal to one-half 
the distance of the diagonal of the suite. In a large suite, this 
would be achieved by extending another corridor perpendi- 
cular to the public corridor for the secondary exit. 

In spite of these issues, especially with a floor plate as 
large as that shown in Figure 2-2, setting in the stair on one 



120-0" 




CORE AREA: 

MECH. ROOMS 
PUBLIC RESTROOMS 
STAIRS 
ELEVATORS 
JANITOR RM. 




1600 SF 



11,484 SF RENTABLE PER FLOOR 
Figure 2-1. Floor plan, building shell. 



end provides great flexibility with respect to the size of 
suites that may be accommodated. It should be noted 
that the stairwells themselves must be located with a sep- 
aration (generally measured to the center of each door) of 
one-half the diagonal of the floor. 



Structural Support 

The structural support system for the building should 
allow as much flexibility as possible for the layout of ten- 
ant spaces. For a multistory building, a moment-resistant 
steel frame offers considerably more flexibility in space 
planning and window placement than does a building 
supported with "K" braces, for example. Of course, 
moment-resistant steel is a considerably more expensive 
option. Regardless of the type of system used, it is imper- 
ative that the structural engineer work very closely with 
the medical space planner, so that structural elements 
can be accommodated within the planning grid. 

Perimeter columns, ideally, would be flush with the 
inside face of the exterior wall (Figure 2-2) so that they do 
not protrude into the room or, at the least, are flush with 
the exterior face of the building so that protrusion into the 
room is minimized. On the interior, columns for a 32-foot 
bay depth would fall as shown in Figure 2-3 on the inside 
face of the public corridor wall, spanning 32 feet 6 inches 
center to center, creating a column free space in 
between. 

For a 44-foot bay depth, the intermediate column 
should occur either 17 or 18 feet on-center, measured 
from the column on the exterior wall, and depending upon 
whether it is flush with the exterior face or extends totally 
from the inside of the exterior wall (Figures 2-4 and 2-5). 
Here, there will be a 12-foot-deep row of rooms across 
the exterior wall. There would then be a 4-foot-wide corri- 
dor, and the column should fall on the far side of the cor- 
ridor, extending into the center row of rooms (Figure 2-5, 
lower diagram). Obviously, one would not want that inter- 
mediate column to fall within the corridor space. 



8 General Parameters of Medical Space Planning 



-II 



MAXIMUM ALLOWABLE - 
DEAD-END CORRIDOR 



I 



wmmm 



h 



I 




PUBLIC CORRIOOR 






19,200 SF 

Figure 2-2. Floor plan, building shell. (Design: Jain Malkin Inc.) 



Building Shell Design 9 




13,500 SF RENTABLE PER FLOOR 

Figure 2-3. Floor plan, building shell. (Design: Jain Malkin Inc.) 



10 General Parameters of Medical Space Planning 



i6o'-tv 




12,360 SF RENTABLE 

Figure 2-4. Floor plan, building shell. (Design: Jain Malkin Inc.) 



1^1 

\ — 1 1 Til ITY 



UTILITY SHAFT (TYP.) 
H.V.A.C./PLUMB./ELECT. 



Building Shell Design 11 



1 32'-0" CLEAR 1 






6"± 6"± 










11' 


-6"± 




4-0" 




15'-6"± 














CLEAR 












1 














1 






1 






32-6" 






1 

L 


o 

Q 


< 


1 










^ 


S 














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O 


o 












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<r 












O 
















h- 














X 






6"± 6"± 






DO 
Z> 


















CL 




11' 


-6"± 




4'-0" 




27'-6"± 














CLEAR 












I 




18' 


-0" 
















f 










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44' 


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Figure 2-5. Placement of columns. (Design: Jain Malkin Inc.) 



Another option for locating the intermediate column in 
a 44-foot-bay depth is illustrated in Figure 2-3. It occurs in 
the wall of the business office or waiting room, making it 
34 feet on center, measured from the column on the exte- 
rior wall. 

It is difficult to give absolute dimensions for locating 
columns, because there are so many variables. The "box- 
in" size of the columns, whether one uses 4-foot-wide or 
5-foot-wide interior corridors, and the fact that high-rise 
buildings have larger columns, affect the spacing 
between them. 

Locations of structural columns should not adversely 
affect the flexibility of the space, if the building is engi- 
neered properly. Most rooms are small; thus, the density 
of partitions is high. Long spans are not necessary. A 
tradeoff inevitably arises here. Reducing the span 
between columns makes it possible to use lighter-weight 
beams, thereby reducing the cost of the building. 
However, more columns, closer together, reduce space 
planning flexibility. The occurrence of perimeter columns 
at intervals, creating 20-foot-wide or 24-foot-wide bays, 
and interior columns spaced as shown in Figure 2-4, 
often works well. Where the spaces on both sides of the 
corridor are a 32-foot depth, all columns may be con- 
tained in the perimeter walls, with none occurring within 
tenant spaces. 



PLANNING MODULE 

A considerable amount of standardization exists in the 
sizes of rooms in a medical suite. For the most part, 
suites can be laid out on either a 4-foot or a 4-foot 6-inch 
planning grid. Having said that, however, one must 
acknowledge the odd-sized treatment rooms, toilets, and 
specialty rooms such as radiology. 

The author prefers a 4-foot planning module. Based on 
this, there are four common bay depths that accommo- 
date efficiently suites of certain sizes. To begin with, a 28- 
foot bay depth works well for small suites anywhere from 
500 to 1500 square feet. It can even accommodate an 
1 800-square-foot suite as shown in Figure 2-6. These 



12 General Parameters of Medical Space Planning 



160'-0" 




11,256 SF RENTABLE PER FLOOR 



Figure 2-6. Floor plan, building shell. {Design: Jain Malkin Inc.) 



Planning Module 13 



suites are extremely easy to plan because they involve 
two 1 2-foot-deep rows of rooms separated by a 4-foot- 
wide corridor. 

A 32-foot bay depth is the most common and ac-com- 
modates suites anywhere from 1200 to 3000 square feet. 
This is similar to the 28-foot bay depth in that it is also a 
double-loaded corridor, except that the row of rooms clos- 
est to the public corridor is 1 6 feet deep. This is where the 
waiting room and business office would generally be 
located. A 3000-square-foot suite, at a 32-foot bay depth, 
would be 92 feet long and would involve long walking dis- 
tances. Therefore, a 3000-square-foot suite would be 
accommodated better in a 44-foot bay depth where a 
center core, or island, may be used. 

A 44-foot bay depth works well for suites between 1 800 
and 4000 square feet. Figures 2-3 and 2-6 illustrate how 
a central core may be used. With suites less than 1800 
square feet, a 44-foot-bay depth does not allow enough 
windows. It creates a narrow, deep suite. 

Suite Bay Depths 



28 feet • suites 
32 feet • suites 
44 feet • suites 
60 feet • suites 



500 to 1 ,500 square feet 
1 ,200 to 3,000 square feet 
1 ,800 to 4,000 square feet 
4,000 to 10,000 square feet 



For purposes of illustration, an identical suite is creat- 
ed in a 28-foot bay depth and a 44-foot bay depth in 
Figure 2-6, and in a 32-foot bay depth in Figure 2-3. 
Consultation rooms are 12x12 feet, and exam rooms are 
usually 8X12 feet in size. Minor surgery rooms are gen- 
erally 12X12 feet. Thus, a fairly predictable layout of 
rooms can be expected. 

If suites are laid out with a storage room at the end of 
a corridor, as shown in the 798-square-foot suite in Figure 
2-6 and in the suites in Figure 2-3, a tenant can expand 
into an adjoining suite by eliminating the storage room 
and continuing the corridor, with no other remodeling nec- 
essary in the existing suite. 

Suites over 4000 square feet work well in a 60-foot bay 
depth. Starting at the public corridor wall and moving 



toward the exterior wall, this allows for a 16-foot-deep row 
of rooms, a 4-foot-wide corridor, two 1 2-foot-deep rows of 
rooms back to back, another 4-foot corridor, and a 12- 
foot-deep row of rooms parallel to the exterior wall. One 
may have a number of transverse corridors running per- 
pendicular to the two aforementioned ones, as illustrated 
in the block diagram in Figure 2-2. This bay depth works 
for suites anywhere from 4000 to 10,000 square feet. It is 
not impossible to design a suite less than 4000 square 
feet in a 60-foot bay depth; however, unless it is a corner 
suite with windows on two sides as shown in Figure 2-2, 
it becomes a narrow, deep suite with few windows. 

Suites over 10,000 square feet, depending on the size 
of the building, may become a full-floor tenant. In this 
case, if they were a tenant in the building shown in Figure 
2-3, the suite would have a bay depth of 82 feet. In the 
building shown in Figure 2-4, the tenant could take one- 
half of the floor (to the right of the center stair) and 
achieve a large square space. The third stair, centrally 
located, would provide the two required exits for the ten- 
ants on the other half of the floor. 

One cannot state unequivocally, for example, that a 
4000-square-foot suite would be more efficient in a 44- 
foot bay depth than in a 60-foot bay depth. The type of 
medical specialty, penetrations of stairs and elevators, 
and the spacing between columns may, in an individual 
building, make one bay depth preferable to another. If 
both are available in the building, it would be wise to pro- 
vide alternate layouts to see which works best. The read- 
er is referred to the radiology suite in Figure 5-5 for an 
example of a 7400-square-foot suite that runs in an "L" 
shape along the 44-foot bay depth and continues across 
the end of the building. 

If one designs a medical building so that suites on one 
side of the public corridor have a depth of 32 feet, and 
the other, a depth of 44 feet (Figures 2-3 and 2-4), one 
would have considerable flexibility to place tenants where 
the suites can be laid out most efficiently. If feasibility 
studies prepared prior to the design of the building shell 
show that there is a considerable need for large suites, 
then one side of the building might be designed at a 60- 
foot bay depth. Sometimes a suite can be laid out equal- 



14 General Parameters of Medical Space Planning 



ly well in two different bay depths, and the only differ- 
ence may be that one requires more circulation area 
than another. 

The average medical suite for a solo practitioner 
would be 1200 square feet. Few suites are smaller than 
that. The bulk of suites the designer will encounter fall in 
the range of 1200 to 2500 square feet. There may be 
large orthopedic or internal medicine suites ranging from 
3500 to 8000 square feet. Since the terms of financing 
often specify that the building must be 50 percent pre- 
leased before construction begins, it is often possible to 
know who the large tenants with special needs will be, 
and the building can be shaped with those requirements 
in mind. 

An MOB constructed purely on speculation with little 
preleasing would be difficult to plan without a profile or 
feasibility study of physicians in the area, their space 
needs were they to lease space, and their respective spe- 
cialties. 



feet wide on center, as they would be when using a plan- 
ning module of 4 feet. 

The 3-foot planning module provides bay depths of 33, 
45, and 60 feet. A 33-foot bay depth would have, starting 
at the exterior wall, a row of 12-foot-deep rooms, a corri- 
dor of 5 feet, and a 1 6-foot-wide row of rooms near the 
building's public corridor. The only compromise occurs at 
the end of the building where, if one has continuous win- 
dows wrapping the building with mullions on a 3-foot grid, 
a corridor of 5 feet, rather than 6 feet, puts a partition in 
the center of a lite of glass. This irregularity occurs only 
on the ends of the building. 

Considering a 45-foot bay depth, starting at the exteri- 
or wall, one would have a 10-foot-wide row of rooms, 5- 
foot-wide corridor, another 5-foot-wide corridor, and a 15- 
foot-deep row of rooms along the public corridor. 



Window Placement 



Alternate Planning Module 

In recent years, there has been a trend toward larger 
exam rooms as well as wider internal corridors. This is 
difficult to accomplish with a planning module of 4 feet, 
since three windows 4 feet wide would lead to a room 12 
feet wide, whereas 9 or 10 feet would be the goal for the 
width of a "large" exam room. Some prefer an exam 
room 9 feet widexl2 feet long, yet others prefer more of 
a square room 10X10 feet or 9X10 feet in size (Figure 
3-40). A wider exam room allows the door to open to 
shield the patient and still preserve the handicapped 
access setback on the pull side of the door (Figure 
3-38). Internal corridors would be 5 feet, rather than 4 
feet clear. 

Although at first it seems an odd number, a planning 
module of 3 feet will work well, provided the shell archi- 
tecture and facade also comply (Figure 2-7). Windows, 
and columns, have to tie to the 3-foot grid. This provides 
exam rooms that are 9 feet wide, center to center, or 8 
feet 6 inches clear, and consultation rooms that are 12 



Window placement is a significant issue in a medical 
office building. With so many small rooms, it is important 
that windows fall in the right place and that structural 
columns occur on the coordinates of the planning module 
so that they can be buried in the walls. Windows with mul- 
lions at 4 feet on center function well when a 4-foot plan- 
ning grid is utilized. This permits exam rooms to be 8 feet 
wide (7 feet 6 inches clear) and consultation rooms to be 
12 feet wide (11 feet 6 inches clear) along the window 
wall. The 4-foot window module can be reduced to a 2- 
foot module to permit even greater flexibility, but this 
amounts to an increased construction cost. When win- 
dows are irregularly sized, or something other than the 4- 
foot module, partitions have to jog in order to meet a mul- 
lion. 

It is important that windows start at 42 inches off the 
floor so that cabinets can be put under them, and patient 
privacy in an exam room is not violated. Even in a waiting 
room or lobby, windows should not start at the floor 
because it limits the area of seating. The glazing color 
should be gray, not bronze, because the latter tends to 
make skin look jaundiced. 



Planning Module 15 



PLASTIC SURGERY 




DEI "|EE 

PERIODONTICS SUfTE 



GENERAL PRACTICE 



BUILDING FL OOR PLAN ON 3 FEET PLANNING GRID 

15,720 SF 

Figure 2-7. Floor plan, building shell, using a 3-foot planning module. (Design: Jain Malkin Inc.) 



16 General Parameters of Medical Space Planning 



Ceiling Heights 

An 8-foot or 8-foot 6-inch ceiling height is suitable for indi- 
vidual suites with the exception of a few individual rooms 
such as radiology, outpatient surgery, or physical therapy, 
which require a 9- or 10-foot-high ceiling. A standard sus- 
pended acoustic ceiling works well, but ideally, for 
acoustical reasons, should be laid out individually in each 
room with interior partitions extending above the finished 
ceiling 6 to 9 inches. 



AMENITIES 



the building that faces the corner might be sculpted or 
articulated in such a way as to make it more dramatic. 

Sometimes, in an attempt to make an architectural 
statement, the exterior of the building will have a stair- 
step configuration. This can greatly reduce the efficiency 
of the suites unless careful consideration is given to the 
length of each staggered section to make sure that a row 
of rooms will fit within it. Niches in the exterior wall can be 
even more of a problem, resulting in very irregular room 
shapes. Buildings that are oval or have a circular config- 
uration are next to impossible to utilize for medical office 
buildings. 



When a dentist or physician evaluates one building 
against another, various factors are considered in addi- 
tion to lease terms and a possible equity position. 
Amenities such as a health club, a conference center, 
dedicated parking for physicians, and a coffee shop or 
deli may make one building more attractive than another. 
A building's image is important, but less so than for cor- 
porate users, who will generally seek out the most 
upscale building their budgets will allow. 

Physicians try to tailor the image to their patient profile. 
Plastic surgeons and other specialists who perform large- 
ly elective procedures may be more interested in a high- 
profile building. However, a primary care physician with a 
broad spectrum of patients may choose a more modest 
building that will not make low-income patients feel 
uncomfortable. This physician would be more interested 
in other attributes of the building such as freeway access, 
convenient parking for patients, and proximity to the hos- 
pital. 



BUILDING SHELL CONFIGURATIONS 



BUILDING STANDARDS 

It is important to define building standards for tenant 
improvements in order to establish an acceptable level of 
quality for construction items. These building standards 
would normally be prepared by the medical space plan- 
ner for review by the owner and tenant improvement con- 
tractor. The items included are construction details for 
each type of partition, sound attenuation, suite entry 
hardware, door closers, interior doors, casework style 
and details, plumbing fixtures, ceiling system, light fix- 
tures, electrical hardware, interior finishes, design of 
reception window, and so forth. 

These items are generally accepted by all tenants in the 
building. Some may wish to upgrade light fixtures, add 
wallcoverings, or upgrade the carpet, but the basic con- 
struction items will be consistent throughout the building. 
This assures the owner, who has to maintain the building, 
that replacement parts will be on hand, and, if a tenant 
moves out, the owner won't be left with a suite having 
French Provincial residential hardware, for example. 



The building shell configurations illustrated in this chapter 
are straightforward and highly functional. Other consider- 
ations sometimes prevail. The site may be best suited to 
a square building, a cruciform building, or perhaps one in 
a T shape. If located on a prominent corner, the part of 



TENANT IMPROVEMENT ALLOWANCES 

Owners or developers offer tenants a tenant improvement 
allowance, expressed as a per-square-foot amount, to 
build their suites. These amounts vary from building to 



Tenant Improvement Allowances 17 



building and also reflect geographical differences in con- 
struction costs. At the lower end of the spectrum, tenants 
cannot build even a simple suite without adding $25 to $30 
per foot, from their own pockets, to the allowance. At the 
upper end of the spectrum, tenants may be able to build a 
"plain vanilla" suite (one with minimum casework, building 
standard lighting, and painted walls) at the tenant 
improvement allowance, without adding money to it. 

Generally speaking, tenants don't expect to be able to 
build a medical or dental suite within the tenant improve- 
ment allowance. Suites such as family practice, pedi- 
atrics, and dermatology, however, would be less expen- 
sive to build than an ophthalmology suite, for example, 
which has a great deal of electrical work. 

At the upper end in terms of construction cost would be 
radiology suites, oral surgery, ambulatory surgical cen- 
ters, and many dental suites. All of these contain a great 
deal of plumbing, electrical, and special construction 
details that make them extremely expensive to construct. 
For this reason, physicians and dentists are highly desir- 
able tenants. They invest so much in tenant improve- 
ments that they move infrequently. Commercial office ten- 
ants often move every few years, whereas it is not unusu- 
al for a physician to occupy a space for 1 to 1 5 years. 

An alternate method of dealing with tenant improvements 
is to present tenants with a work letter stipulating exactly 
how many of each item (i.e., lineal feet of casework, number 
of electrical outlets, number of doors, lineal feet of partitions) 
they will receive per. 1000 square feet of rentable space. 
These quantities are tied to the per-square-foot allowance. 
In theory, if the tenant did not exceed those quantities of 
each item, per 1000 square feet, the suite would be built 
with no out-of-pocket expenses. 



POLITICS 

When designing tenant suites, one becomes aware of a 
fundamental issue: conflicting goals of various parties 
regarding tenant privileges and limitations. Of particular 
concern are ownership of the building (whether the ten- 
ants may participate in ownership), tenant improvement 



allowances offered by the owners, whether tenants may 
have their own radiology equipment, and whether tenants 
will be permitted to engage their own contractors. 

In essence, owners generally want to give as little as 
possible but lease the building quickly and at high rents, 
and tenants want to move into custom suites, designed 
according to their every whim, without having to foot any 
out-of-pocket expenses. The tug-of-war usually contin- 
ues until the tenant actually takes occupancy of the 
suite, and then, little by little, the issues seem to resolve 
themselves. However, the space planner is often caught 
in the middle. 

If retained by the owner of the building to do space 
planning for the tenants, the designer's obligation is to 
protect the rights of the owner; when employed by an indi- 
vidual tenant, the designer is charged with negotiating 
with the building owner to secure the greatest number of 
goods for the tenant. When one is the space planner for 
the building and also engaged to provide custom interior 
design services for a tenant, one must wear two hats and 
represent both parties well. 



LEASING CONSIDERATIONS 

Leasing a medical building requires a great deal of strat- 
egy. It is helpful if the leasing agent is experienced in 
dealing with physicians. Targeting one or two key physi- 
cian groups is the best way to kick off the leasing effort. 
Physicians are often reluctant to be the first to lease 
space in a new building. It takes a couple of leaders who 
are not afraid to risk being first in order to interest other 
physicians. The strategy involves determining who those 
key physicians are and going after them. Their interest in 
the project signals the seal of approval to others in the 
medical community. 

Strategy also comes into play when determining opti- 
mum locations for various suites within the building. 
Some of this is a factor of the building shell itself, as 
suites of a certain size might be better accommodated in 
one location than another. Apart from that consideration, 
however, high-volume suites are best located, if not on 



18 General Parameters of Medical Space Planning 



the ground floor, then at least near the elevator, to limit 
foot traffic down the corridor. 

Radiology, due to the weight of the equipment, would 
usually be found on the ground floor and, for ease of 
access, so would the clinical lab. Specialties such as gen- 
eral practice or internal medicine, which use radiology 
and lab services a great deal, would wisely be located 
adjacent to those suites. Low-volume specialties such as 
plastic surgery, neurology, or cardiac surgery might be 
located on upper floors, perhaps in a corner suite. 

For corner suites, one would not locate a 1500-square- 
foot tenant in a choice corner. These suites should be saved 
to use as an inducement to woo a prime tenant. Remember, 
however, when a suite is located across the end of a build- 
ing, if the suite is of sufficient size to require two exits, there 
will have to be a separation between them. This is some- 
times difficult to achieve at the end of a building. 

Another issue to think about when laying out suites on 
a floor and taking into account the tenant's preference for 
location is that it is important to not leave any "holes" or 
unleasable size spaces between suites. In order to avoid 
this, tenants cannot always be located exactly where they 
would wish to be. This is where the space planner's skill 
as a mediator comes into play. 

The first tenants to express interest in a new medical 
building are often radiology, clinical lab, and pharmacy, 
but they are often the last actually to confirm a lease 
since they depend on the other tenants for their liveli- 
hood. If the building is only 50 percent leased upon com- 
pletion and these tenants have to move in, they will suf- 
fer. Furthermore, they will want to know, in advance of 
signing a lease, who the major tenants are, so that they 
can project whether the composition of the building will 



generate enough revenue for them. A fully equipped radi- 
ology suite represents an investment of several million 
dollars in equipment and construction costs. Such equip- 
ment is not easily relocated. Understandably, such ten- 
ants want very specific information on the other tenants in 
the building before committing to a lease. 



HOSPITAL-BASED MOBs 

Medical office buildings that are adjacent to and affiliated 
with hospitals have very special needs that will be 
touched on only briefly in this discussion. The major con- 
sideration lies in the interface with the hospital. Will the 
hospital actually be occupying space in the MOB? If so, 
and if inpatients have access to these facilities, the MOB 
will be subject to more stringent standards and codes, 
thereby greatly increasing construction costs. 

If the MOB is to be physically connected to the hospi- 
tal, great thought must be given to the configuration of 
each floor with regard to stairwells, elevators, and point of 
entry to the hospital, so that future expansion is not ham- 
pered, and circulation between the hospital and the MOB 
is efficient. One disadvantage to physicians in a hospital- 
affiliated MOB is that sometimes the hospital imposes 
limitations upon individual tenants whose services or 
practices are likely to compete with hospital departments. 
This is particularly true of diagnostic imaging, clinical lab, 
physical therapy, and pharmacy services. 

Hospitals benefit by having on-campus MOBs to pro- 
vide a core group of admitting physicians who are loyal to 
the hospital. This also increases utilization of the hospi- 
tal's ancillary services. 



Hospital-Based MOBs 19 



CHAPTER 3 



Practice of Medicine: 
Primary Care 



The field of medicine is continually expanding as new 
knowledge and concepts are put into practice. But at the 
base level of the health care delivery system, we begin 
with the primary fields of medicine: general practice, pedi- 
atrics, family practice, and internal medicine. Physicians in 
these areas are responsible for the total healthcare needs 
of their patients. They are termed "primary" medical spe- 
cialties because they are normally the entry-level physi- 
cian one would consult about a medical problem. 

If the problem requires a specialist, the family practi- 
tioner or internist will then refer the patient to a specialist 
— perhaps a urologist, neurologist, orthopedist, or aller- 
gist. There are certain obvious exceptions to this primary- 
care referral system. People frequently consult allergists, 
plastic surgeons, dermatologists, obstetricians and gyne- 
cologists, or orthopedists on their own if they feel certain 
they have a problem that falls into that specialist's domain. 

While a primary physician may refer patients to a spe- 
cialist to consult on a special problem, he or she will be 
in contact with the specialist and will retain overall 
responsibility for the patient's care. This provides for 
continuity of care — one physician who records a contin- 
uing health history for a patient and who oversees and 
coordinates total healthcare over a period of years. This 
is particularly important for patients with long-term dis- 
abilities such as diabetes, heart disease, or hyperten- 
sion. In managed-care systems, the primary-care refer- 
ral physician is often called the "gatekeeper," since 
access to specialty care is controlled by this individual. 



A general practitioner (G.P) is a doctor who, having 
completed medical school and an internship, began his 
or her medical practice. A G.P. gains a broad general 
knowledge through experience that enables him or her 
to treat most medical disorders encountered by his or 
her patients. Doctors in family practice have had at least 
three years' training and service in all major areas of 
medicine such as surgery, obstetrics and gynecology, 
pediatrics, internal medicine, geriatrics, and psychiatry. 
The practice of family medicine is based on four princi- 
ples of care: continuity, comprehensiveness, family ori- 
entation, and commitment to the person.* For the pur- 
pose of space planning, the needs of general practice 
and family practice physicians are identical. 



FAMILY PRACTICE 

The individual rooms that comprise this suite, with modifi- 
cations, form the specialized suites to be discussed in 
future chapters. Together, these rooms constitute the basic 
medical suite. 

Therefore, the philosophy behind the design of these 
individual rooms (waiting room, business office, exam 
room, consultation room, nurse station) will be discussed 
in depth in this chapter. 



*l. R.. McWhinney, An Introduction to Family Medicine, Oxford University Press, 
New York, 1981. 



20 



Functions of a Medical Suite 



1 . Administrative 

a. Waiting and reception 

b. Business (appointments, bookkeeping, insur- 
ance, clerical) 

c. Medical records 

2. Patient care 

a. Examination 

b. Treatment/minor surgery 

c. Consultation 

3. Support services 

a. Nurse station/laboratory 

b. X-ray, darkroom 

c. Storage 

d. Staff lounge 

Figure 3-1 shows the relationship of rooms. The patient 
enters the waiting room, checks in with the receptionist 
(usually an opening or window with a transaction counter 
between the business office and waiting room), and takes 
a seat in the waiting room. Since most medical offices 
require advance appointments (as opposed to walk-ins), 



Family practice. 




Figure 3-1. Schematic diagram of a family practice suite. 



the nurse will have pulled the patient's medical record 
prior to the patient entering the office. 

Later, a nurse or medical assistant calls the patient to the 
examination area. Usually, the nurse or assistant will then 
weigh the patient, request a urine sample (if required), 
record blood pressure, and take a short history. This is done 
either at the nurse station or in the exam room. The nurse 
may also record the patient's temperature. 

In the exam room, the nurse or aide prepares the 
patient for the examination and arranges the instru- 
ments the physician will need. The doctor enters the 
room, washes his or her hands, chats with the patient 
about symptoms, makes notes in the patient's chart, 
and proceeds to examine the patient, often with a nurse 
or assistant in attendance. After the examination, the 
patient is asked to dress and may be instructed to meet 
the physician in the consultation room, where a diagno- 
sis and recommended treatment are discussed. As it 
slows down the physician to have to return repeatedly 
to a consultation room with each patient, more com- 
monly, the doctor diagnoses and prescribes right in the 
exam room. The patient leaves the office, passing an 
appointment desk or window where future appointments 
may be booked and where payment for services may be 
made or arranged. 

Obvious deviations to the above may occur when, for 
example, a patient breaks a limb. In this case, the patient 
may be sent to an X-ray room first, and then proceed to a 
minor surgery room to have a cast applied without ever 
entering an exam room. 



Flow 

The efficiency of the medical practice will be largely influ- 
enced by the flow of patients, staff, and — to a lesser 
degree — supplies through the suite. The layout of rooms 
must be based on a thorough understanding of how staff 
interface with patients and, most important, separation of 
incoming and outgoing traffic. This is rarely possible in a 
small office for one or two practitioners but is increasing- 
ly important as the size of the office grows. 



Family Practice 21 



In Figure 3-2, for example, exam rooms and consulta- 
tion rooms are arranged in four clusters, enabling four 
physicians to practice simultaneously. It assumes a fifth 
physician will, at any time, have a day off. Patients, after 
checking in with the receptionist, proceed to one of four 
nurse stations to be weighed. If a urine specimen is 
required, toilets between each two nurse stations have 
specimen pass-throughs. For those arriving for lab work 
only, or for those who know they need lab work after hav- 
ing visited the physician and who are now on their way 
out of the suite, the lab is conveniently located near the 
waiting room. The exit/check-out path of travel is more or 
less separate from the ingress, and patients can exit from 
both sides of the suite without passing through the wait- 
ing room. Circulation for staff is direct, enabling them to 
quickly access all parts of the suite without having to nav- 
igate a maze. Medical records and the business office are 
centrally located. 

Electronic Communication Systems 

Flow can be enhanced and managed by custom light-sig- 
naling communication systems that consist of a panel of 
colored signal lights mounted on the wall of exam and 
procedure rooms, nurse stations, and the reception area. 
By glancing at a panel or pressing a button, physicians 
and staff can silently be notified of messages and emer- 
gencies, let others in the office know where they are 
located, and tell nurses and technicians where they are 
needed. The sequence memory program advances auto- 
matically, telling the doctor which patient is next. Monitor 
panels at nurse stations indicate at a glance the status of 
exam rooms, while another panel at the reception desk 
notifies clinical staff when patients have arrived and 
which provider they're scheduled to see. Expeditor 
Systems of Alpharetta, Georgia, is a leading vendor of 
these systems. 

An add-on to the Expeditor communication system, 
called Practice Profiler®, provides room utilization analy- 
sis and documentation of the entire patient encounter. It 
measures the time a patient spends waiting in the exam 
room before the doctor arrives, the amount of time the 
doctor spends with the patient, and a monthly report on 



physician and staff productivity is e-mailed to subscribers. 
This type of data can help physicians become more effi- 
cient in the eternal quest to see more patients each day 
without sacrificing quality. 



Physician Extenders 

In recent years, physicians — especially those in group 
practices — have increasingly added physician extenders 
(PEs) to their patient care management teams. Also 
referred to as "mid-level providers," these generic terms 
usually refer to physician assistants (PAs), medical assis- 
tants (MAs), and advanced practice nurses (APNs). 
According to the American Association of Colleges of 
Nursing, APNs are advanced registered nurses, typically 
with master's degrees, who fall into four categories: 

1 . Nurse practitioners, who provide primary-care diag- 
nosis and treatment, immunizations, physical exams, 
and management of common chronic problems 

2. Certified nurse midwives, who provide prenatal, post- 
partum, and gynecological care to healthy women, 
and deliver babies in a variety of settings 

3. Clinical nurse specialists, who are trained in a range 
of specialized areas such as oncology, cardiac care, 
and pediatrics 

4. Certified registered nurse anesthetists, who, accord- 
ing to the American Association of Colleges of 
Nursing, administer more than 65 percent of all anes- 
thetics given to patients 

At least 45 states allow advanced practice nurses to 
prescribe medications, and 16 states allow APNs to prac- 
tice independently without physician supervision. 

Clearly, the use of physician extenders dovetails with 
the economics of managed care. Studies by the Medical 
Group Management Association (MGMA) and the 
American Medical Association (AMA) Center for Health 
Policy Research indicate that PEs can increase a physi- 



22 Practice of Medicine: Primary Care 



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FAMILY PRACTICE SUfTE FOR 5 PHYSiCIANS 

7270 SQUARE FEET 

Figure 3-2. Space plan for family practice, 7270 square feet. {Design: Jain Malkin Inc.) 



□ O 



3 C 






OT 



nooc£r\ ff 




ft 



NURSE STATION 



KOMtll 




a 



D 
ip 



D 



SB 



^ 



Family Practice 23 




Figure 3-3. Primary care, community clinic, physician extenders' office. {Architecture: Moon 
Mayoras Architects, San Diego, CA; Interior design: Jain Malkin Inc.; Photographer: Steve 
McClelland.) 



Figure 3-4. Primary care, community clinic, physician extenders' office (opposite side of room). 
(Architecture: Moon Mayoras Architects, San Diego, CA; Interior design: Jain Malkin Inc.; 



cian's productivity and income and that patients are gen- 
erally pleased with the quality of care delivered. Under 
Medicare regulations, services provided by a PA in most 
physicians' offices are reimbursed the same as if provid- 
ed by a physician. 

If the medical practice includes physician extenders, 
they will require shared or private offices, based on the 
tasks they perform and their roles in the practice (Figures 
3-3 and 3-4). Thus, a four-physician office with two PAs 
and one NP is a seven-provider office for the purpose of 
determining the number of exam and treatment rooms. 



Office of the Future 

Two forces — managed care and digital technology — are 
exerting pressure on physicians to rethink the process of 
how they practice medicine. These pressures are particu- 
larly painful for mid-career and older physicians who may 
not be as comfortable with digital technology as young 
physicians and for whom the severe decline in reim- 
bursement and the loss of control in determining the 
course of treatment for a specific patient are barriers to 
the way they are accustomed to practicing medicine. 



24 Practice of Medicine: Primary Care 



Change is indeed difficult and access to healthcare is a 
vital, as well as emotional, issue. What health plans and 
third-party payers will cover and what the physician 
believes is best for the patient are often at odds, creating 
great tension. It's not that younger physicians find this sit- 
uation less frustrating, but their expectations may be 
lower since they were familiar with the new environment 
in which healthcare is practiced prior to entering medical 
school. They knew what they were getting into and one 
might even say that anyone going into medicine now 
must have the heart of a missionary as one can no longer 
expect it will lead to a life of wealth and privilege. 

As healthcare becomes more of a commodity, "pro- 
cessing" more patients in less time is a strategy for deal- 
ing with low reimbursement and the ever-growing 
demand for care. However, most physicians don't want to 
run in and out of exam rooms, spending mere minutes 
with each patient, never really getting to know them or to 
develop a trusting relationship. This sets the stage for 
looking at a new way of practicing medicine that uses 
physician extenders for more routine examinations as 
well as digital technology to free up more time for the 
physician to spend with the patients who require complex 
diagnostic assessments. 

The re-engineering of clinic and physicians' office envi- 
ronments to optimize provider utilization and enhance 
patient satisfaction has been the goal of a consortium of 
medical equipment manufacturers founded by Welch 
Allyn and Midmark Corporation, leaders, respectively, in 
the areas of diagnostic instrumentation and examina- 
tion/procedure tables and modular cabinetry 

Goals of the Office of the Future Project 

1 . Enhance provider productivity through product inte- 
gration, efficient layout, equipment access, and usage. 

2. Eliminate redundancy among various manufacturers' 
equipment, sharing technology platforms wherever 
possible. 

3. Create an overall environment that promotes patient 
satisfaction with the clinical experience. 



4. Take a leadership role in device compatibility related 
to telemedicine, medical information systems, and 
other communication technologies. 

5. Incorporate new tools and technologies previously 
available and affordable only in higher-cost settings. 

6. Maximize cost effectiveness of initial acquisition of 
ongoing operating/support expenses. 

Flexibility and Interconnectivity 

Modularity and flexibility are built into the Office of the 
Future, allowing it to be customized to each provider's 
requirements. Several levels of interconnectivity provide 
for the sharing of images, patient records, admissions 
and accounting information among different sites. The 
Version 4.5 (Figure 3-5) primary-care procedure room 
is the most recent edition, resulting from research and 




Figure 3-5. Office of the Future, Version 4.5, primary-care procedure room. {Photo courtesy: Welch Allyn , 
Skaneates Falls, NY.) 



Family Practice 25 




Figure 3-6. Primary-care procedure room displaying digital instrumentation that can download results 
to an electronic medical record. {Photo courtesy: Welch Allyrf, Skaneates Falls, NY.) 



collaboration among manufacturers. It features automat- 
ed patient identification, computerized medical records, 
and direct data input from medical devices, and it com- 
bines personal computer (PC) and video monitors to 
eliminate redundancy. Integration of multiprocedure 
video platforms (such as sigmoidoscopy and col- 
poscopy) and telemedicine-ready diagnostic equipment 
are also featured, although a colposcope is not includ- 
ed in this photo. 

Multipurpose Procedure Room 

This procedure room has a digital vital signs monitor 
attached to a blood pressure cuff on the countertop. The 
telemedicine mobile cart (rear wall) has a video monitor 
that, when connected to a cable in the wall, can transmit 
an image to a "remote" physician. A PC/CPU (central pro- 
cessing unit) fits inside the cart. The vital signs monitor 
replaces the traditional diagnostic instrument panel on the 
wall at the rear of this room except that it lacks an otoscope 
(for examining ears) and an ophthalmoscope (for examin- 
ing eyes), which (unless one uses the telemedicine cart) 
are available as battery-powered manual instruments. On 
the right in this photo is the Midmark Dressing Nook and, 
on the left, is a Midmark cabinet for storage of endoscopy 
scopes. Thus, this room can be used for many procedures. 
What is unique, and new, is the interconnectivity of these 
diagnostic devices and the fact that they all produce digital 
output that can record directly to an electronic medical 
record and also be transmitted, along with video images of 
procedures, to remote locations for consultation by a spe- 
cialist. In fact, a physician at a remote location can even 
watch the procedure in real time and help "direct" the fiber- 
optic scope or comment during the procedure. 

Manual Versus Digital Instrumentation 

The dramatic contrast between the use of traditional man- 
ual diagnostic instruments and the digital revolution is 
illustrated in Figure 3-6. [The furniture and exam table in 
this photo have been placed, not according to principles of 
medical space planning, but for the sake of illustrating the 
point.] The Welch Allyn/Midmark diagnostic instrument 
panel mounted on the wall relies on the practitioner's sens- 



26 Practice of Medicine: Primary Care 





Figure 3-8. Exam room Dressing Nook. {Photo courtesy: 
Midmark Corporation, Versailles, OH.) 



Figure 3-7. Office of the Future, Version 4.5, primary-care exam room. {Photo courtesy: Welch Allyrf, Skaneates Falls, NY.) 



es — hand to eye and eye to brain — versus automated 
vital signs capture (the instrument on the mobile cart) that 
requires no clinical expertise and could be performed by 
an aide. If one rolls the telemedicine cart into the room, one 
has an otoscope and ophthalmoscope inside the drawer 
that are connected to the video monitor which can capture 
images from these devices for saving to a PC or electron- 
ically transmit them to a telemedicine physician. 

On the cabinet in Figure 3-6 are the Sure Sight™ vision 
screener (item on right) and the AudioPath™ hearing 



screening device, which also does tympanometry. Both 
devices produce digital output that can be connected to 
an electronic medical record. 

The Office of the Future, Version 4.5, primary-care 
exam room (Figure 3-7) features similar interconnectivity 
of diagnostic devices as does the procedure room. One of 
the productivity features is the Midmark Dressing Nook 
(Figure 3-8), which allows a provider to take a patient his- 
tory or chart while talking to the patient who is undress- 
ing or dressing. 



Family Practice 27 



Examination Room 

It is clear the "future" has arrived. One can see how the 
practice of medicine will be transformed by digital tech- 
nology. But, psychologically, are physicians ready and 
willing to abrogate their responsibilities and sensory con- 
tact with patients to a machine, to artificial intelligence? 
Physicians who have been in practice for many years 
would likely pride themselves on being able to tell a great 
deal by looking at a patient's skin tone, or examining their 
tongues, or picking up some elusive quality during the 
process of monitoring vital signs. After all, medicine is a 
science and an art. And with interest in integrative medi- 
cine (integration of allopathic or Western medicine and 
complementary therapies) steadily growing, it won't be 
easy to forge a marriage between digital technology and 
energy medicine. Buck Rogers meets Andrew Weil. 

Placebo Effect 

In integrative medicine, rapport between the physician 
and patient is key to a successful outcome. According to 
Herbert Benson, M.D., author of Timeless Healing: The 
Power and Biology of Belief, the placebo effect (belief that 
causes self-healing) is greatly enhanced when the patient 
believes that the physician is capable of healing him; 
when the physician believes in the efficacy of the treat- 
ment; and when, together, there is a belief in the relation- 
ship — rapport has been established. 

In the end, digital technology need not preclude devel- 
oping a warm and caring relationship with patients. By 
automating the more routine aspects of a patient visit, the 
physician may have more time to spend as diagnostician 
and teacher. 



Institute for Healthcare Improvement* 

This nonprofit, Boston-based research and education 
organization, established in 1991, focuses on accelerat- 
ing the pace of improvement in healthcare systems. It 



*AII IHI information was provided by permission of Donald Berwick, M.D., M.P.P., 
President and CEO, Institute for Healthcare Improvement. 



is based on broad collaboration, rather than competi- 
tion, between people and organizations that are com- 
mitted to major reform. Initiatives that might be of inter- 
est to readers of this book are those relating to sub- 
systems of office practice such as workflow and patient 
flow, patient satisfaction, physical office design, and the 
elimination of delays and waiting in all aspects of 
patient care delivery. The organization's mission state- 
ment for the Idealized Design of Clinical Office 
Practices™ project (initiated in January 1999) states that 
it will "design, test, and deploy new models of office- 
based practices ... capable of fundamentally improved 
performance levels, better clinical outcomes, higher sat- 
isfaction, lower costs, and improved efficiency in a more 
rewarding work setting." Forty-two prototype sites from 
23 organizations are participating in this study. Readers 
are encouraged to consult the IHI Web site (www.ihi.org) 
for more information about the innovative work under- 
taken by this organization. A brief outline of the philo- 
sophical principles underpinning the IHI vision for ideal- 
ized office-based care follows. 

Principles for Office-Based Practices 

We believe that the following Principles serve as a foun- 
dation upon which clinical offices will be designed; they 
represent the fundamental underpinnings of office-based 
care. The ideal clinical office will create systems to assure 
that these Principles are achieved. 

1 . Paramount focus on the clinician-patient relationship 

2. Individualized access to care and information at all 
times 

3. Knowledge-based care is the standard 

4. Individuals control their own care to the extent that 
each individual desires 

5. Minimal waiting for all involved in the processes of care 

6. Seamless transfer and communication of information 
and coordination of care 



28 Practice of Medicine: Primary Care 



7. Financial performance sufficient to ensure unhin- 
dered viability 

8. Patient and practice management will be based on 
real-time data, including measures of process, satis- 
faction, finance, outcomes, and epidemiology 

9. Continual improvement and waste reduction in all 
processes and services 

10. Individual health linked to broader community health 

1 1 . A model work environment 

Few can disagree with IHI's premise: 

The clinical office lies at the heart of health care. For 
most patients most of the time, it is the portal of entry, 
the communications hub, the primary locus of care, 
and, in these days of integrated care, the coordinating 
center. For most doctors, too, it is home base; they 
speak of the hospital, but my office. 

Nor can one fail to observe that, despite seismic pres- 
sures on physicians and the healthcare system in gener- 
al, the clinical office practice has changed little in 
decades. 

The average clinical office practice of today bears 
remarkable similarity in form, process, design, and activ- 
ity to the offices of a decade, two decades, even a half- 
century ago. In the typical office setting, patients still 
phone in for appointments, register upon arrival, wait in 
waiting rooms, disrobe in examination rooms, listen in 
consulting rooms, and wave good-bye to the receptionist 
in a sequence of actions that would look nearly identical 
if we could compare, say, 1 950 to 1 998. A few differences 
would be noticeable, of course — the desktop computer 
instead of the typewriter, the otoscope now fiberoptic, 
the furniture modular, the increased ability to provide 
certain treatments such as antibiotics and chemothera- 
peutics, and the credit card taken and checked automat- 
ically. But, the core sequence, the systems that support 
the work and, more importantly, the assumptions about 



what work is to be done, would all be almost identical — 
1950 equals 1998.* 

The Institute for Healthcare Improvement and projects 
like the Office of the Future, although they approach rad- 
ical change from completely different avenues, will likely 
impact the future design of medical offices and clinics. 
The opportunity for redesign is vast. 



Waiting Room 

The waiting room is the patient's introduction to a physi- 
cian or dentist. One forms a first impression of the prac- 
titioner by the image projected in the waiting room. This 
is where psychology plays a significant role. Outdated 
furniture with torn and faded upholstery may simply be 
the result of a doctor's busy schedule or his or her 
reluctance to focus on it as an important aspect of 
patient care. But, whatever the actual reason, such a 
neglected waiting room conveys to a patient that this is 
a doctor who may be as outdated in his or her medical 
expertise and technology as the waiting room indicates. 
The neglect of the waiting room generalizes to other 
areas, and patients may feel that this is a physician or 
dentist who might be neglectful in their care — one who 
manages to slide along with minimum standards. 
Designing the waiting room as a comfortable, cheerful 
space with appealing colors, soft lighting, and attractive 
furnishings is paramount (Color Plate 1, Figure 3-9). 
Note, in this photo, that privacy has cleverly been pro- 
vided at the reception desk by setting it back from the 
waiting room yet openings in the wall in front of it afford 
visibility of waiting patients. A tabletop fountain (Color 
Plate 2, Figure 3-10) is a stress-relieving amenity at the 
entry to the suite. These items are discussed in greater 
detail in Chapter 12. 



"Lecture handout by Charles Kilo, M.D., M.P.H., Idealized Design of Clinical 
Office Practices, Symposium on Healthcare Design, San Francisco, 
November 1998. 



Family Practice 29 











Table 3-1 














Analysis of Program. 












Family Practice 






No. of Physicians: 




1 




2 




3 


Consultation 






12X12=144 


2@ 


12X12=288 


3@ 


12X12=432 


Exam Rooms 




3@ 


8X12=288 


6@ 


8X12=576 


9@ 


8x12=864 


Waiting Room 






12X14=168 




14X18=252 




18X20=360 


Business Office 






12X14=168 




16x18=288 a 




18x30=540 a 


Nurse Station 






8X10=80 


2@ 


8X8=128 


3@ 


8X8=192 


Toilets 




2@ 


7X8=112 


2@ 


7X8=112 


3@ 


7X8=168 


Storage 






6X6=36 




6X8=48 




8X10=80 


Cast Room 




Use Minor Surgery 


Use IV 


linor Surgery 


Use Minor Surgery 


Staff Lounge 






8x10=80 




10X12=120 




10X12=120 


Minor Surgery 






12X12=144 




12X12=144 




12X12=144 


X-ray Area b 






— 




12X25=300 




12x25=300 


Laboratory (if an 


y) 


Combined with nurse station 


10X10=100 




16x16=256 e 


Si 


jbtotal 




1220 ft 2 




2356 ft 2 




3456 ft 2 


20% Circulation 




244 


470 




690 






Total 




1464 ft 2 




2826 ft 2 




4146ft 2 



"Includes insurance clerk, bookkeeper, and office manager, 
includes darkroom, control, film filing, and dressing area, 
includes lab, waiting, and blood draw. 



Security 

Depending on the demographics and location of the med- 
ical practice, the door between the waiting room and the 
medical office may have a lock that can be released by 
the receptionist. Irate patients or those who may be men- 
tally unstable can pose a threat to staff. 

Function and Comfort 

In addition to the psychological aspects of the waiting 
room design, it must, above all, be functional. Unless the 
office is located in a warm climate, the waiting room 
should include a secure space for hanging coats and 
stashing boots and umbrellas (Figure 3-11). A patient 
must be able to enter the room and proceed directly to the 
receptionist's window without tripping over people or fur- 



niture. After checking in, the patient should be able to 
select a magazine from a conveniently located rack, and 
find a seat. When called, the seated patient should be 
able to move quickly into the examination area without 
disturbing other patients. 

Should the patient be disabled, traffic aisles must be 
wide enough to accommodate a wheelchair, and there 
should be an open space in the room where the person in 
a wheelchair can comfortably remain, without clogging 
the traffic flow. Persons who are disabled do not like to 
feel they are a burden to the nonhandicapped population. 
They prefer to be independent, and they must be consid- 
ered in the planning stages of a project so their needs 
and rights to access can be humanely and sympatheti- 
cally handled.* Architects and space planners are familiar 
with the Americans with Disabilities Act (ADA), which 
must be adhered to in any medical or dental office, or 
public building, for that matter. 

Size of Waiting Room 

The size of the waiting room can be determined after 
interviewing the physician and staff (see the Appendix for 
a client interview form). The composition of the doctor's 
patient population and his or her work habits will indicate 
parameters the designer must follow. Common sense dic- 
tates that a physician who sees people without advance 
appointments will need a much larger waiting room than 
one who follows an appointment schedule. 

Low-volume practices such as surgical specialties or 
psychiatry require smaller waiting rooms than do high- 
volume specialties such as general practice, orthope- 
dics, pediatrics, internal medicine, and obstetrics and 
gynecology (OB-GYN). In addition, practices that accom- 
modate a large number of emergencies need a larger 
waiting room. Accident cases will frequently be brought 
through the staff entrance to avoid exposing what might 
be a gory sight to those in the waiting room. The larger the 
patient volume, the larger the waiting room needs to be. 



'Readers are referred to two excellent books on this subject: Beautiful Universal Design 
by Cynthia Leibrock and James Evan Terry (John Wiley, 1 999) and Design Details for 
Health by Cynthia Leibrock (John Wiley, 2000). 



30 Practice of Medicine: Primary Care 




A convenient formula for determining the number of 
seats is as follows: 



Figure 3-11. Built-in brochure rack and closet in clinic waiting area. 
(Architecture: OSM; Photo courtesy: Jain Malkin Inc.) 



2PXD- E=S 



where 



P = Average number of patients per hour (per 

physician) 
D = Number of doctors 
E = Number of exam rooms 
S = Seating 
L = Late factor 

The waiting room must accommodate at least one hour's 
patients. If a physician sees an average of four patients 
per hour, and has three examining rooms, and it is 
assumed that each patient is accompanied by one friend 
or relative, a solo practitioner would require five seats in 
the waiting room: 

2(4) x 1 - 3 = 5 

Because this is a one-physician practice, it would be 
wise to assume that the doctor will run half an hour late, 
so the waiting room must accommodate 1.5 hours' 
patients. This expansion factor can be expressed as: 



2PxD = L 



2(4) X1 =4 



Thus, the waiting room should accommodate S + L, or 
nine persons, plus an area for children, if space permits. 
The late factor can generally be reduced as the number 
of physicians is increased. Using the above formulas for a 
two-physician family practice, including a late factor, 18 
seats would be required: 



2(4) X2- 6 
2(4) X 2 



= 10 

= _S 
18 



A quick rule of thumb is 2.5 seats per exam room 
which, in this case, also yields 18 seats. 

It is important to understand that these formulas are 
only a guide. The specifics of each practice and space 



Family Practice 31 



limitations of the suite will often dictate waiting room 
capacity. The formula, and good common sense, may tell 
you that ideally 45 seats should be provided, but the 
physical limitations of the space and the physicians' intent 
to squeeze in as many exam rooms as possible may limit 
seating capacity to 25. 

In medical space planning, as in life, rarely does the 
ideal prevail. The designer has to skillfully juggle the 
client's requests, the client's budget, building codes, 
structural limitations of the given space, and the princi- 
ples of medical space planning. Tradeoffs and compro- 
mises are the reality from which suites are built. 

Once the number of waiting room seats has been 
estimated, the size of the room can be determined, 
allowing 18 to 20 square feet per person. The author has 
found 18 square feet per person a workable guide for 
the average medical office. Nevertheless, the amount of 
space required for a comfortable waiting room will vary 
according to the room's configuration and the location of 
the entry foyer and the reception window. 



Accommodating Children 

An area may be provided for children. A table and 
chairs or a toy box is welcomed by parents. Special fur- 
niture can be fabricated (see Pediatrics), which will 
keep children occupied, quiet, and out of danger of 
being stepped on. Interactive toys (Figures 3-12, 12-16, 
12-17, and 12-18) available from People Friendly 
Places, Inc. (Northbrook, Illinois), keep young children 
engaged. Keep in mind that a children's corner must be 
located away from door swings or other hazards on 
which children might injure themselves. The children's 
area must be in sight of the receptionist, who is charged 
with keeping order. 



Amenities 

A large aquarium (Figures 3-13, 3-93, and 4-50) is a nice 
addition to a waiting room. It is restful and enjoyed by 



adults and children alike. Other amenities include a desk 
or countertop with a computer and Internet access. 

As medical offices become more digital, it will be nec- 
essary to provide carrels in the waiting room where 
patients can update their electronic medical records. 
Although not yet widespread, it is currently possible for a 
patient medical record to be encoded on a "smart card" 
that can be downloaded at a provider's office. As 
providers address HIPAA, they will be making substantial 
investments in information technology that may require 
accommodation in the way patients are registered, 
processed, and followed during their care. Futurists pre- 
dict that the home will increasingly become the site for 
healthcare: Patients will self-monitor their vital signs, 
which will simultaneously be transmitted to a provider's 
office, and telemedicine-type consults will enable the 
physician and patient to see each other and speak in real 
time (see the two figures in the Introduction). A prescrip- 
tion can be sent via the Internet directly to a pharmacy; 
however, appropriate security measures mandated by 
HIPAA will have to be in place. 

A considerable amount of educational literature is dis- 
pensed in some offices. Wall-mounted brochure racks 
prevent a cluttered appearance (Figures 3-11, 12-3). 



Patient Privacy 

Some physicians prefer maximum communication 
between front office staff and patients and favor a wait- 
ing room separated from the business office by only a 
low partition. Although this may comfort the patient psy- 
chologically by removing what may be perceived as a 
barrier, it often results in a loss of privacy for staff, who 
frequently have to discuss delicate matters with a 
patient. The patient might suffer embarrassment, know- 
ing that the adjacent waiting patients may overhear the 
conversation. 

For this reason, many offices use a 4- to 6-foot-wide 
window with a plastic laminate shelf, starting at 42 inches 
off the floor (Figure 3-1 4). It should be noted that the ADA 
(Americans with Disabilities Act) requires accommoda- 



32 Practice of Medicine: Primary Care 




Figure 3-12. Interactive play toy engages toddlers. {Photo courtesy: 
People Friendly Places, Inc., Northbrook, IL) 



tion for wheelchair users at 34-inch countertop height; 
however, a section of 30-inch-high counter is even friend- 
lier (Color Plate 3, Figure 3-15). This means either the 
entire reception transaction counter be no higher than 34 
inches or a portion of it be at that height. A sliding glass 
window may be added for additional staff privacy, but it 
does convey a negative image of closing out the patients. 
If glass is used, it should always be clear, not obscure, so 
that patients have visual contact with staff. 

There is a tradeoff here in that lowering the countertop 
to 30 or 34 inches exposes all the clutter (and there is usu- 
ally a lot) on the desktop as well as the unsightly backs of 
computers. If a section of the reception counter has a 42- 
inch-high transaction shelf, it makes it easy for patients to 
sign in or to write a check without bending. On the staff 
side, it provides space for storage of frequently used 




Figure 3-13. Aquarium adds interest to waiting room. (Design: Jain 
Malkin Inc.; Photographer: John Christian.) 



Family Practice 33 




Figure 3-14. Reception window, internal medicine suite. (Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



forms in a slotted rack (Figure 3-16) and also conceals 
staplers, tape dispenser, telephone, and other items as 
well as keeps confidential paperwork away from prying 
eyes. 

A decorative vertical panel or frosted glass (Figures 
3-17 and 3-18) can be added to a 30-inch-high work sur- 
face to conceal the back of the monitor. As flat-panel 
monitors become more commonplace, accommodating 
the bulky cathode ray tube (CRT) will cease to be an 
issue (Figure 7-8). 

To deal effectively with issues of patient privacy when 
designing the waiting room, do not place chairs too close 
to the reception window; position the receptionist's tele- 




Figure 3-16. Built-in cubby-hole slots for office forms at reception desk 
eliminate the clutter of tiered letter trays. (Interior design: Jain Malkin 
Inc.; Photographer: Steve McClelland.) 



34 Practice of Medicine: Primary Care 




[Image not available in this electronic edition.] 



Figure 3-17. Street-level registration desk, primary-care community clinic. 
{Architecture: Moon Mayoras Architects, San Diego, CA; Interior design: Jain 
Malkin Inc.; Photographer: Steve McClelland.) 



Figure 3-18. Patient check-out features privacy screens between patients, frosted 
glass panels to conceal backs of computers, and exquisite lighting treatment (see 
Figure 4-17 for space plan). Memorial Breast Care Center at Anaheim Memorial 
Hospital, Anaheim, CA. (Architecture and interior design: Taylor & Associates 
Architects, Newport Beach, CA; Photographer: Farshid Assasi.) 



Family Practice 35 



phone to the side of the window opening to help mask 
conversations; and provide an area, in the front office, 
where staff and patients may discuss a sensitive topic 
without it being overheard (Figure 3-18, Color Plate 3, 
Figure 3-19, and Figure 3-22). 



Toilet Rooms 

There is disagreement as to the practicality of providing a 
toilet room in the waiting area. It saves staff the trouble of 
frequently directing patients to the bathroom of the exam- 
ination area, but it has the disadvantage of patients emp- 
tying their bladders before the nurse can request a urine 
specimen. In pediatric offices, however, a toilet in the 
reception area is desirable to enable mothers to change 
a baby's diaper (see Figures 3-84 and 3-85). Ceramic tile 
floors and wainscot are the most practical long-term fin- 
ishes for bathrooms. For little additional cost, an interest- 
ing tile pattern can be created as in Figure 3-20. Note that 
dark grout is optimal on the floor to conceal stains. Dark 
tile provides excellent contrast with white sink and toilet 
for low-vision individuals. The wall-hung sink in this photo 
meets the ADA requirements and conceals the unsightly 
P-trap drain. 



Reception 

Since the receptionist often books appointments and 
maintains the day's schedule, she must see the patient 
on arrival and just before leaving. She must also have a 
good view of the waiting room from her chair so that she 
can see who is waiting (Color Plate 3, Figure 3-19). Few 
practitioners use manual appointment books now as 
computers are preferable. Despite working on a comput- 
er, adequate "clear" countertop work space is required, 
in addition to a place for the phone and to write mes- 
sages; a place for a printer, fax machine, and countertop 
copier (for copying insurance eligibility cards) nearby; 
and, if possible, an L-shaped return facing the corridor 
appointment "good-bye" window so that, while remaining 



seated, she can swivel around, greet an exiting patient, 
book an appointment, or accept payment for services 
(Figure 3-21). 

In an office with two or three front office staff, the 
appointments/cashier workstation and reception window 
may be separated (Color Plate 3, Figure 3-19) to provide 
greater privacy for the exiting patient. 




s*s* ss8 \ % 




Figure 3-20. Clinic bathroom is both functional and attractive. Montefiore 
Medical Center in the Bronx. {Architecture and interior design: Guenther 
Petrarca, New York, NY; Photographer: ©Christopher Lovi.) 



36 Practice of Medicine: Primary Care 



■52'-0" 




GENERAL PRACTICE 



1664 SF 
Figure 3-21. Space plan for general (family) practice, 1664 square feet. (Design: Jain Malkin Inc.) 



Front office personnel may occasionally help in the 
back office, assisting the doctor in the examining room at 
times, weighing patients, or recording histories, but usu- 
ally their duties will be confined to the business office. 

It is desirable to design the business office in such a 
way that staff can easily cover one another's station. An 
efficient layout can sometimes mean that one fewer per- 
son is required, considerably reducing the overhead. 



Patient Education 

Patient education is an important part of healthcare that 
many physicians try to accommodate in their suite 
design. It is generally located at the front of the suite, and 
may even be an alcove off the waiting room. For reasons 
of privacy, however, it is advisable to create a room, per- 
haps 8x10 feet, and build carrels or partitions between 



Family Practice 37 



patients. A 30-inch-high countertop would have a small 
television monitor, and a videocassette recorder (VCR) 
would be housed in an open compartment underneath 
(Figure 4-135). Shallow cabinets provide storage space 
for videotapes. Tapes cover all sorts of topics: presurgical 
instructions, information about various diseases or 
injuries, ways to lower health risks, and they may even 
allow a patient to view his or her own surgery. The use of 
videotapes allows the doctor to communicate a great deal 
of information, in a professional manner, without having to 
explain each concept or procedure personally. 



Business Office 

Frequently referred to as the front office in medical jargon 
(versus the back office or examination area), this is the 
heart of the medical office. Appointments are scheduled 
here; patients are billed; medical records are stored here; 
patients are greeted from this room; and routine insur- 
ance and bookkeeping duties are performed here. 

In a small practice, two people may perform all these 
tasks. In a large practice, several persons may occupy the 
business office. A convenient rule of thumb is one secre- 
tary for each two doctors in a low-volume practice and one 
secretary per physician in a high-volume practice. If a 
physician is seeing four to six patients per hour, the sec- 
retary may be spending more time with patients than the 
doctor does, since the secretary's work would involve 
arranging and rescheduling patient appointments on the 
telephone whenever the doctor is delayed or has to 
rearrange his or her daily schedule, filing medical charts, 
sending reports to referring physicians, billing patients, 
collecting money, filing insurance claims, answering the 
phone, and ordering supplies. In larger practices, there is 
more division of labor — one individual does billing and 
collections, another accounts payable, another insurance, 
a medical records clerk, a transcriptionist, and so forth, as 
well as an office manager or administrator. 

A convenience in the business office is a gate door with 
a plastic laminate shelf or a 30-inch-high section of coun- 
tertop that has a piano hinge to enable staff to lift it to exit 



the room. Either of these options permits communication 
with patients as they are exiting the office and suffices for 
brief greetings or a routine discussion about a bill without 
the patient having to enter the bookkeeper's or the busi- 
ness office. 

Depending on the width of the corridor (the standard 
corridor width is 48 inches clear; however, in high-volume 
suites, 60-inch width is preferable), the gate door might 
be located in a recess or alcove so that a patient who 
stops to chat will not be blocking corridor traffic (Figure 4- 
56). However, for longer conversations and more privacy, 
the patient would enter through that door and proceed to 
the bookkeeper's office. A guest chair should be provided 
in the bookkeeper's office for this purpose. 

Workroom and Storage Needs 

Unless one has worked in a medical business office, or at 
least spent several days observing the flow of paper and 
communication, it is difficult to plan adequately sized 
work spaces, storage areas, and accommodation of 
equipment. Furthermore, upper cabinets are often too 
high for the average 5-foot-4-inch woman to reach; the 
cabinets — if 12-inch overall depth — may be too shallow 
to house reams of paper, boxes of envelopes, and com- 
puter forms, and they are often poorly utilized. It is not 
uncommon for front office staff to say they have no stor- 
age space only to find the upper cabinets only 25 percent 
full. A series of full-height cabinets at least 15 inches 
deep with adjustable shelves is far more practical. 
Alternatively, one could provide a workroom as in Figure 
4-160 off of the business office, and out of public view, 
with simple open shelves, a countertop for postage 
meter, printers, fax machine, and space for a floor model 
copier, if needed. It is always desirable to place copiers in 
a room that is well ventilated and has no occupants. 
Copiers, especially large floor models, are a health haz- 
ard in terms of air quality. Sometimes the rear wall of the 
appointments/check-out counter accommodates the 
workroom function (Figure 3-22). Note the vertical slots 
on the left-hand side for patient charts. 

Another option is to create a workroom (Figures 3-23 
and 4-19) at the entry to the business office as this pro- 



38 Practice of Medicine: Primary Care 




Figure 3-22. Friendly sit-down height check-out/appointment desk at 
Montefiore Medical Center in the Bronx (family practice clinic). The 
rear wall provides space for fax machine, copier, and supplies. 
(Architecture and interior design: Guenther Petrarca, New York, NY; 
Photographer: Lynn Massimo.) 




Figure 3-23. Business office workroom accommodates several printers 
with paper feed slots in cabinet below, fax machine, and floor model 
copier (out of view) on opposite wall. Business office staff access it 
from one end and clinic staff from the other. Scripps Breast Care 
Center, La Jolla, CA. {Interior architecture and design: Jain Malkin Inc.; 
Photographer: Glenn Cormier.) 



vides easy access to others in the clinic for faxing, copy- 
ing, and printing without having to disturb those working 
in the front office. Do not underestimate the number of 
machines and equipment that may have to be accommo- 
dated, including a large shredder and/or storage contain- 
er for confidential material (anything with patients' names, 
test results, reports) that will be picked up by a contract 



vendor for shredding. HIPAA regulations regarding confi- 
dential handling of patient data will increase the need for 
paper shredding. 

Clearly, the issue is not just having enough storage, but 
having it where it's needed, so that one does not have to 
keep getting up to get forms that are frequently used; one 
does not tear one's stockings due to inadequate knee 



Family Practice 39 



space; the countertop is neither too shallow nor too deep; 
adequate clear desk space is available despite a com- 
puter, telephone, typewriter, calculator, pencil sharpener, 
stapler, reference books, and possibly a credit card 
machine. Cubbies for forms are quite useful (Figure 3-1 6) 
in keeping the desk clear of clutter. 

Casework and Countertops 

It has been standard in the design of medical offices to 
build in all workstations in the business office, insurance, 
transcription, and similar areas. Lining the perimeter of 
the room with 24- to 30-inch-deep plastic-laminate-clad 
countertops takes full advantage of every inch of space in 
a way that freestanding desks or workstations rarely do, 
especially in small rooms or irregularly shaped spaces. 

Having said that, it is easy to mindlessly draw counter- 
tops, turning the 90 degree corner, and continuing, plac- 
ing a task chair every 5 feet, giving the client false confi- 
dence that an efficient work space has been carefully 
developed for each of these persons, without truly taking 
into consideration the tasks each performs and the way in 
which they interface with patients and coworkers. Staff 
move into the space and are shocked to learn that their 
equipment barely — or possibly doesn't — fit. The paper 
feed on their large printer requires a 15-inch grommeted 
slot in the countertop, there is no space for the hospital 
printer, and the space between the countertop and the 
42-inch-high transaction shelf where two manuals are 
kept for ready access is half an inch too short. A 5-foot- 
long countertop space at 24-inch depth does not place 
the computer screen at an ergonomic viewing distance, 
the keyboard does not fit on the countertop, and, without 
a keyboard tray, there is not enough clear work space to 
handle papers or write notes. 



Ergonomic Considerations 

Work surfaces designed for computer monitors should 
allow the screen to be positioned at least 18 inches from 
the front of the keyboard tray. Getting it elevated to a com- 
fortable viewing height can be a problem. The modular 



work station in Figure 3-24 takes advantage of the corner 
depth. Despite ergonomic research on optimal distances 
and conditions, considerable individual variation and pref- 
erences exist. WorkRite Ergonomic Accessories, Inc., 
Novato, California, offers numerous products that enable 
workers to meet individual needs. One of the most useful 
products is a metal insert that spans a standard right- 
angled countertop, creating a diagonal "bridge" and 
thereby adding considerable space in front of the CRT. 
Another useful item is the multiple-adjustment arm that 
lifts the CRT off the desk, getting it to whatever height the 
worker desires and also freeing up desk space. The 
patented PowerLift™ feature quickly shifts the CRT from 
sit-down to stand-up height. The vendor's Web site 
(www.backbenimble.com) helps buyers select appropri- 
ate ergonomic accessories by "walking" them through all 
the tasks they perform until the total order is configured. 



Improving Ergonomics 

A solution to concealing the back of the monitor, at the 
same time resulting in more usable desktop area, is pro- 
vided by NOVA® Office Furniture, Inc. This unit allows the 
user's head to be oriented slightly downward instead of 
tilted back, which is more common and often results in 
neck strain (Figure 3-25). It is sold as a component that 
can be built into freestanding desks or custom millwork. 
NOVA has done considerable research to design a prod- 
uct that reduces eyestrain and musculoskeletal com- 
plaints (Figures 3-26 and 3-27), but it requires meticulous 
location of overhead lighting to avoid glare on the glass. 
It seems to work best in reception/admitting functions 
where the desktop CRT can become a barrier between 
staff and patient. The downside is that when a new 
employee occupies the workstation, if this "option" is not 
embraced, retrofitting the desk can be costly. NOVA 
works well in large nurse stations where numerous mon- 
itors can take up desktop space and nurses are merely 
accessing information, rather than doing word process- 
ing. Another solution for lowering the height of monitors is 
shown in Figure 10-90. 



40 Practice of Medicine: Primary Care 




Figure 3-24. Modular workstation puts computer screen at proper viewing distance and provides lowered shelf for keyboard. (Photo courtesy: Steelcase Inc., 
Grand Rapids, Ml.) 



Family Practice 41 




Figure 3-25. Desk features recessed computer with dark glass, antiglare 
cover. {Photo courtesy: Nova Solutions, Inc., Effingham, IL. Covered by vari- 
ous U.S. patents.) 




CREATING THE CORRECT DOWNWARD GAZE ANGLE™ WORKSTATION 
*Remove Monitor Base. 

1 . Screen should point slightly above the 
user's face (bottom edge of monitor 

is nearer to the eye than top edge). 

2. Install monitor as high as possible without 
raising glass. 

3. Preferred position: top edge of monitor 
is at back edge of glass. 

Figure 3-26. Illustration of the NOVA workstation. (Photo courtesy: Nova Solutions, Inc., 
Effingham, IL. Covered by various U.S. patents.) 



It is necessary to spend considerable time interviewing 
the office manager and key staff to understand how they 
work and perhaps offer advice on a more efficient layout 
than they have considered. Realize that they may be 
reluctant to admit that they cannot understand the space 
plan or be able to visualize the adjacencies inherent in 
the plan, nor may they be able to interpret the casework 
elevations and locations of electrical outlets, phones, or 



computer connections. Thus, it is necessary to demon- 
strate with a tape measure, foam core, or other tools crit- 
ical distances, heights, and spaces. 

Computer Systems 

Today, all medical and dental offices are computerized. 
Some offices use computers only for word processing 
and for billing. Others use computers to link their offices 



42 Practice of Medicine: Primary Care 




Figure 3-27. Illustration of the NOVA® workstation with critical dimen- 
sions. (Photo courtesy: Nova Solutions, Inc., Effingham, IL. Covered 
by various U.S. patents.) 



with the hospital and with support services such as a lab- 
oratory or radiology group. This enables a doctor to 
preadmit a patient to the hospital, book radiology proce- 
dures, or schedule surgery, and receive an immediate 
reply. 

Practitioners with a totally computerized office will have 
sophisticated software that handles appointment sched- 
uling, patient accounting, patient histories, patient and 
insurance billing, revenue projections, collection letters, 
referring physician reports, patient medication data 
reports, statements, and insurance claims tracking. With 
an integrated software system, patient data can be tabu- 
lated to produce a variety of reports that allow the practi- 
tioner to analyze the practice. These may include cross- 
referencing of diagnoses and procedures and demo- 
graphic analysis of marketing efforts. 

Although countertops that accommodate computers 
need to be deep enough to keep a large monitor at the 



proper ergonomic viewing distance, they must not be so 
deep that it creates back strain if the employee needs to 
reach over it to transact business with patients. Keyboard 
trays and ergonomic task chairs with multiple adjust- 
ments reduce workers' compensation claims and absen- 
teeism and increase productivity. 

The number of peripheral items connected to the com- 
puter can consume considerable space. If the office has 
a dedicated computer that is networked with the hospital, 
this will generally be located in the front office. Other 
computers will be proprietary to the medical practice and 
generally networked to each other. Printers must be care- 
fully placed close to those who use them most to prevent 
employees from having to continually walk over to the 
printer to retrieve something. 

It is important to be aware of the effects of glare from 
overhead lighting and from windows when laying out 
workstations using CRTs. Glare causes reflections on the 
screen that lead to eyestrain and stress. 



Bookkeeping 

Some practices use an outside bookkeeping service. The 
daily charges for service and payments received are 
recorded and forwarded to the bookkeeping service, 
which, in turn, handles billing and collections. Monthly 
reports are sent to the physician. In this case, space for 
billing and collections can be minimized as in Figures 3-35 
and 4-159. Occasionally, a large practice will have its own 
billing office off site in less expensive accommodations. 

In many offices, the bookkeeper is in a separate room 
adjacent to, but not part of, the business/reception area. 
The insurance secretary may also have a separate office 
to provide working conditions with fewer interruptions. The 
business office of a busy practice is an extremely hectic 
place. Phones ring continually; people are rushing around. 
It is not a good place for people who need concentration. 
If space permits, it is always better to protect the book- 
keeper and insurance secretary by giving them private 
offices. Sometimes modular workstations are used to pro- 
vide privacy when private offices are not feasible. These 



Family Practice 43 



often have paper management accessories and hinged 
flipper-door storage to make use of vertical surfaces. 



Insurance 

Most medical treatment is paid by third-party payers — 
insurance companies. Under managed care, many indi- 
viduals are enrolled in HMOs whereby a monthly prepaid 
fee entitles one to receive healthcare, often with a co-pay 
at each visit. Much has been written about the complexity 
and mountains of paperwork associated with billing (and 
collecting from) insurance companies, which is compli- 
cated by the lack of uniformity among them in terms of 
billing forms and procedures. This amounts to a great deal 
of paperwork, and a medical office of any size usually has 
at least one full-time employee doing nothing but insur- 
ance forms. He or she requires a desk with an L- or U- 
shaped return, a computer, one or two printers, and 
access to medical records and to the copy machine. 
Numerous file cabinets are needed, as well as open-shelf 
storage, for the multitude of business forms and manuals. 
A guest chair should be provided for a patient. As govern- 
ment control increases, more and more procedures are 
covered by third-party payers, and the personnel required 
to process these forms has steadily increased. It should 
be noted that it is now possible to process claims elec- 
tronically (paperless) with many of the large insurance 
companies, which speeds the process. 



Medical Transcription 

Medium-volume to large-volume practices often have a 
part-time or full-time medical transcriptionist who works 
from dictation tapes and transcribes the physicians' 
notes. This task is best accommodated in a separate 
room since an environment with little distraction is opti- 
mal. Only a countertop work surface is required. It should 
be 30 inches high with a fully adjustable keyboard tray. A 
small room is adequate, provided it has a window and 
natural light. 




Figure 3-28. Dictation niche. (Design: Jain Malkin Inc.; Photographer: 
John Christian.) 



Some physicians send their tapes out of the office for 
transcription; others may have a dictation line to a word 
processing unit on the telephone. The notes would be 
recorded and the typed manuscript would be delivered 
to the physician's office. Voice recognition software is 
another option that appeals to some physicians. 



44 Practice of Medicine: Primary Care 





Figure 3-29a. Exam room physician/patient interface using computer with patient management 
and clinical best practices databases integrated with an electronic medical record. {Photo cour- 
tesy: Physician Micro Systems, Inc., Seattle, WA.) 



Figure 3-29b. Examination room physician/patient interface with physician using handheld 
computer with patient management and clinical best practices databases, activated by a 
light pen. {Photo courtesy: Cerner Corporation, Kansas City, MO.) 



Dictation 

Occasionally, a physician will request a dictation niche 
(Figures 3-28 and 4-3) in the corridor central to the exam 
rooms to be used after examining each patient, rather 
than saving it for the end of the day. This is also a good 
place to locate a wall-mounted telephone so that the doc- 
tor can take a quick call without returning to the consulta- 
tion room. An X-ray view box and an open storage com- 
partment for X-ray films would be essential features for 
many, but not for all, physicians (Figure 3-28). Some 
physicians prefer to dictate in the exam room while the 
patient is still present, and it seems likely this will be the 
preferred site with electronic medical records and the pre- 
viously described interconnectivity of diagnostic instru- 



mentation and total patient management systems 
(Figures 3-29a and 3-29b). 

Office Manager 

Large offices frequently have an office manager or a busi- 
ness manager who hires personnel, orders supplies and 
drugs, and assists the physicians in secretarial or busi- 
ness matters in the capacity of executive assistant. The 
office manager should have a private office. It need not be 
large — 10x12 feet is adequate — and it should be locat- 
ed so that it faces the business office. In fact, the walls 
facing the business office may have glass, starting 48 
inches off the floor, so that the manager can oversee the 
staff at all times (Figure 3-52). 



Family Practice 45 



Medical Records 

An important function of the business office is the storage of 
medical records. In order to protect the physician from legal 
complications, as well as to provide continuity of care for 
patients, accurate records must be maintained where they 
are easy to retrieve. Primary physicians keep more exten- 
sive and more detailed records than urologists or radiolo- 
gists, for example, who see patients on a referral basis. 



The preferred method of record storage is the lateral 
file cabinet (Figure 3-30). This may be a cabinet without 
doors (Figure 3-31), or with retractable doors that store in 
the top of each shelf opening. The shelves may be sta- 
tionary, or they may pull out for easier access. When filing 
is done laterally, the file folder tab must be on the side so 
that it sticks out of the file cabinet. 

Color-coded file jackets are the most efficient system 
for medical offices (Figure 3-32). The standard file jacket 










Figure 3-31. Open-shelf filing cabinet. (Photo courtesy: Tab Products, Vernon Hills, IL.) 



Figure 3-30. Lateral file cabinet. (Photo courtesy: Tab Products, 
Vernon Hills, IL.) 



46 Practice of Medicine: Primary Care 



accepts 8X1 1-inch papers, but radiology files require 
jumbo file jackets, which are 14x17 inches. The patient's 
name may be encoded alphabetically, by color, and/or 
number. Thus, a misfiled folder immediately becomes 
obvious, as the colors do not conform to the surrounding 
jackets. 

Additionally, one can encode by color special features 
such as the sex of the patient, certain unusual medical 
disorders, or the date the patient initially sought consulta- 
tion. This facilitates pruning files for inactive charts or 
selecting case studies of patients with various medical 
disorders for follow-up. Various companies manufacture 
these specialized file jackets with the color-coding sys- 
tem. Ames Color File (Sommerville, Massachusetts) pub- 
lishes a particularly good brochure explaining the details 
and refinements available with this system of medical 
record storage. 

Group practices frequently utilize a large room for med- 
ical records with a mechanical retrieval system. This elim- 
inates the need for aisles in front of all shelves, since the 
files move to the operator, and the access aisle is in front 
of the operator. This equipment can be purchased with 
manual controls or it may be motorized (Figure 3-33). 

It is not necessary to buy factory-fabricated file cabi- 
nets. They may be custom built on the job, particularly if 
the space allotted to medical chart storage does not 
accommodate standard file cabinet widths. These job- 
built file storage units would consist of open shelves with 
a clear height of 12 inches. However, steel file cabinets 
have the advantage of being able to be moved to anoth- 
er office, they provide greater fire resistance, and they 
can be locked for security. 

Prefabricated file units without retractable doors are 
less expensive and offer open-shelf easy access to 
charts (Figure 3-31). Small- to medium-sized offices may 
use space-saving files that are two cabinets deep with the 
front one sliding on a track (Figure 3-34). 

It is important for the designer to project the physician's 
future needs for medical chart storage in the new office. 
The designer must ascertain, from the client interview, 
the number of new patients added to the practice each 
week or month. That number would be projected for three 




Figure 3-32. Color-coded file jackets and accessories. (Photo courtesy: Tab Products, Vernon Hills, IL.) 

to five years (the length of most medical leases) and 
added to the existing number of medical charts. The thick- 
ness of charts must also be factored into the equation. 
Physicians who see many patients with chronic condi- 
tions may have many charts 2 inches thick, whereas a 
surgeon's charts may be estimated at four per inch. 
Charts should be pruned each year to eliminate patients 
who have not been seen in three years. These "aged" 
charts can be placed in storage at a local warehouse that 
offers a quick retrieval system for physicians. 

Medical records should be located so that they are 
convenient to the receptionists, nurses, and bookkeeper. 
Charts are usually pulled in the morning for patients to be 
seen that day. The only other time staff would need 
access to charts would be primarily for phone calls or pre- 



Family Practice 47 




Figure 3-33. Medical records room utilizing high density motorized filing 
system. (Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.) 



Figure 3-34. Sliding file system. SIDE-TRAC®. {Photo courtesy: Tab Products, Vernon Hills, IL.) 



scription refills. Medical records would normally be locat- 
ed in the business office, but could be placed elsewhere 
in the suite. The bookkeeper needs convenient access to 
medical records for billing patients and filing insurance 
claims. Occasionally, for patients who are involved in liti- 
gation, attorneys and legal assistants will come to the 
office to copy charts. 



Electronic Medical Records 

Although contemplated as "the future" a number of years 
ago, the electronic medical record (EMR) has been slow 
to win the hearts and minds of physicians. According to 
Rosemarie Nelson, Welch Allyn's Office of the Future 
Director, as of this writing (the year 2001 ), fewer than 3 to 



48 Practice of Medicine: Primary Care 



5 percent of physicians have electronic medical records. 
It may be 10 years down the road before physicians' 
offices are totally electronic with completely integrated 
systems of medical records, billing, scheduling, as well as 
digital diagnostic instruments, analyzers, weight scales, 
and tools for recording vital signs that are networked and 
record data in real time on the patient's electronic medical 
record. In theory, the physician would type input on a 
handheld or laptop computer (Figures 3-29a and 3-29b), 
which transmits it directly to the patient's chart. When the 
patient exits the room, all data will have been recorded on 
the chart. By use of a "smart card" (a small card that can 
be carried in the wallet with a computer chip that has the 
patient's medical record), the patient would not have to 
continually repeat his or her medical history each time a 
provider is consulted or a visit to the emergency room is 
made. 

A company called MediVation (medivation.com) devel- 
ops, for medical practices, a home page, and then cre- 
ates private pages, with full security, for each patient. The 
patient can receive personal messages that are pass- 
word protected. 

Technology currently exists that will enable the patient 
to download a medical-social family history form, fill it out, 
but not have to submit it over the Internet. When it is 
downloaded from the physician's office, it prints with a bar 
code. When the patient brings it into the physician's office, 
it is scanned with a bar code scanner that downloads the 
information to the patient's medical record. 



Private Entrance 

A medical office, regardless of size, must have two 
entrances — one for patients and a private one for the 
doctor, so that he or she can enter the office without 
meeting patients in the waiting room (Figure 3-35). In 
large suites, usually over 3000 square feet, local building 
codes may require two exits (separated by a distance 
equal to one-half the length of the maximum overall 
diagonal dimension of the area served, measured in a 



straight line between exits). Occasionally, to save space, 
the staff entrance is through a room such as the staff 
lounge, the business office, or a special procedures 
room, although the latter option is less desirable (Figures 
4-52, 4-107, and 4-133). 



Examination Room 

Good traffic flow is imperative for the efficiency of a med- 
ical office. Several factors influence the location of the 
exam rooms: 

1 . Nurses are responsible for controlling traffic to and 
from the exam rooms, so the nurse station and exam 
rooms should be clustered together. This enables 
nurses to prepare the patients in each room quickly, 
while traveling back and forth to the nurse station to 
clean instruments or obtain items needed for the 
examination (Figures 3-2 and 3-35). 

2. Exam rooms must be close to the consultation room 
to save the physician unnecessary steps, but it is 
preferable that patients not pass the consultation 
room when making their way to the exam room, 
although this is sometimes unavoidable. 

3. The exam room corridor(s) should be arranged so 
that patients must pass the business office when exit- 
ing the suite (Figures 3-53 and 3-104). This provides 
control so that future appointments may be booked, 
medications explained, and payment for services dis- 
cussed. A convenient feature is a full-height, 12-inch- 
deep recessed storage cabinet for drug samples 
located in the corridor near the check-out area to 
enable the provider to dispense a product as the 
patient exits (Figures 4-113 and 4-120). 

The exam room is the background for diagnosis. As 
such, it should be designed very functionally, with an 
understanding of the equipment that needs to be provid- 
ed and the psychological needs of the patient (refer to 



Family Practice 49 



78-0" 




Figure 3-35. Space plan for family practice, 3300 square feet. Centralized nurse station enables physicians to write orders at transaction shelf. The business office and billing func- 
tions are off site. {Design: Jain Malkin Inc.) 



50 Practice of Medicine: Primary Care 



Chapter 1). If the amenities of the room can help the 
patient relax (wallcovering, flooring, color, and artwork), it 
makes the examination easier. 

It is desirable that patients' vital signs (blood pressure, 
pulse, etc.) be at normal levels prior to an examination. 
Anxiety, resulting from fear of a clinical and unfamiliar 
environment, elevates patients' vital signs and may give 
false readings. This is often referred to as "white coat syn- 
drome." Numerous journal articles have noted how often 
this condition leads to elevated blood pressure and 
results in healthy individuals being treated for hyper- 
tension. 



Physician/Patient Interface 

A number of journal articles have been written about the 
physician/patient interface with respect to increasing 
patient satisfaction and patient compliance (adherence to 
treatment and drug regimens). In general, these studies 
have demonstrated that specific interview techniques can 
be employed by the practitioner to achieve these goals, 
but there is another aspect related to the rapport estab- 
lished between doctor and patient. Even a brief encounter 
of several minutes face to face with the physician can 
enhance patient satisfaction if the patient feels he or she 
has the full attention of the physician and if rapport has 
been established. This leads one to wonder if the exam 
room layout and furnishings could be reconsidered from 
this perspective, placing the patient and physician eye to 
eye to achieve greatest rapport (Figures 3-36 and 3-37). 
An excellent annotated bibliography on doctor-patient 
communication is available from the American Academy 
on Physician and Patient in New York City. 

A future challenge will be to integrate a computer 
screen or laptop computer into the exam room, enabling 
both the physician and the patient to look at it together. It 
will be possible with a Microsoft Windows® platform to 
view, on one screen, an X-ray, a lab report, charting notes 
from a previous visit, and even a video image of an 
endoscopy procedure. Assuming flat-panel monitors will 
eventually become the norm, integrating them into a 




Figure 3-36. Patient exam room puts patient eye to eye with physician and also provides space for a family member 
or siblings. Family Practice Clinic at Frisbie Memorial Hospital, Rochester, NH. {Architecture and interior design: 
TRO/The Ritchie Organization, Newton, MA; Photographer: Edward Jacoby.) 



"compact" setting will be less difficult than working with 
bulky CRTs. 

Layout 

Looking at the room in Figure 3-38, the physician, upon 
entering the room, can easily walk to the sink to wash his 
or her hands, pivot around to face the patient on the exam 
table, reach for instruments on the countertop with the left 
hand, and examine the patient with the right. This room 



Family Practice 51 




Figure 3-37. Combined examination and consultation room, known as a "Mayo room," enhances patient/physician rapport by eliminating the traditional desk as a barrier. 
Built-in X-ray view box facilitates discussion of films. A newer version of this room would accommodate access to digital diagnostic images and electronic medical 
records. Mayo Clinic, Scottsdale, AZ. (Architecture and interior design: Hammel Green and Abrahamson, Inc., Minneapolis, MN; Photographer: Mark Boisclair.) 



52 Practice of Medicine: Primary Care 



7'-6" - 9'-0" 

(WIDTH OF ROOM MAY VARY) 



-# 



CD 

I 



STOOL 




EXTENSION 




CHAIR 



EXAM 
TABLE 



CU_RTAIN_ 
TRACK 

MIRROR 



MAGAZINE- 
RACK 




TYPICAL EXAM ROOM 



Figure 3-38. Standard examination room layout. (Design: Jain Malkin Inc.) 









r-O 



EQ. , EQ. , EQ 



-7f 



24" 24" 
7 . 



-2 ADJUSTABLE 
SHELVES 

-PAPER TOWEL 
DISPENSER 

-SHARPS CONTAINER 
-GLOVES 



TYPICAL EXAM CABINET 



layout puts the physician on the patient's right side, which 
is standard, even for most left-handed practitioners. 
Physicians are trained to examine from the right side as 
this makes it easier to palpate certain organs. It should be 
noted that an attempt to place plumbing back to back 
(mirror image) will result in left- and right-handed exam 
rooms. This is foolish economy. Every exam room should 
be identical in layout to be efficient so that the practition- 
er has the same degree of comfort and orientation in 
each room. One could almost draw a vertical line through 
this room dividing it into two zones — the right side for the 



physician or provider and the left for the patient. In a 
"right-handed room," the entry door will be on the right 
side and the exam table on the left, as one would face the 
room upon entering. 

Despite this rationale, one may find practitioners with 
other preferences such as in Figure 3-39 where the sink 
cabinet faces the wall with the door (this layout wouldn't 
work were there windows on this wall), although the 
physician still addresses the patient from the right side. 
The patient is exposed as the foot or stirrup end of the 
exam table faces the door, but a cubicle drape can be 



Family Practice 53 




Figure 3-39. Examination room. Montefiore Medical Center in the 
Bronx. {Architecture and interior design: Guenther Petrarca, New York, 
NY; Photographer: ©Christopher Lovi.) 



pulled across the width of the room. The wooden wall 
panel behind the wall-mounted examination instruments 
is an attractive feature of the room. 

Size 

The first functional consideration is size: 8x12 feet is the 
ideal size for exam rooms (gives a clear dimension of 7 
feet 6 inchesxl 1 feet 6 inches inside the room) as it com- 
fortably allows for a full-size exam table, a built-in sink 



cabinet with storage above, dressing area, small writing 
desk (usually wall mounted), a stool on casters for the 
doctor, a guest chair for the patient, a treatment stand (if 
required), and perhaps a small piece of portable medical 
equipment. 

If the room is used for purposes other than routine 
examinations, such as stress testing, the room would 
contain an electrocardiogram (ECG) unit and a treadmill, 
as well as an exam table, and it should be 9X12 feet or 
10X12 feet in size. If a dressing area is not required, the 
length of the room can be shortened to 10 feet. 

The reader may wish to refer to Chapter 2 for a dis- 
cussion of alternate sizes of exam rooms with respect to 
planning grids. Practitioners may prefer a wider exam 
room (9x12 feet) as in Figure 3-40 or even a square 
room 10x10 feet as in Figure 3-40 although, if these 
occur on exterior walls and the planning grid is 4 feet, the 
wall will have to jog 2 feet one way or the other (creating 
an awkward unusable space in front of the window) to ter- 
minate at a mullion. 

Dressing Area 

If space permits, it is desirable to provide a dressing area 
for patients. This need be no more than a 3-x3-foot, sur- 
face-mounted drapery cubicle track at the ceiling (with 
radius corner), with a built-in bench or a chair, clothes 
hooks, hangers, a mirror, and perhaps a shelf for dispos- 
able gowns. It provides patients with privacy in undressing. 

The alternative is that patients must disrobe in the 
open exam room, with the fear that the nurse or doctor 
may walk in on them while they are naked or while they 
are squeezing into a girdle or pantyhose. Older people, 
and those with orthopedic girdles or braces, tend to be 
more sensitive about this than younger people. 

There is also the possibility of creating a private dress- 
ing alcove with a 30-inch-wide door or panel hinged to the 
wall. It is perpendicular to the wall when in use and folds 
flat against the wall when not in use. The chair can be 
used either inside the dressing area when the hinged 
panel is extended or outside when the panel is folded flat 
against the wall. Called the Dressing Nook, such a prod- 
uct is currently manufactured by Midmark Corporation 



54 Practice of Medicine: Primary Care 



A PLANNING GRID OF THREE FEET 
RESULTS IN EXAMS 9 X 12 FEET, OR 
8-6" X 11'— 6" CLEAR DIMENSIONS. 
THE EXTRA WIDTH MAKES IT POSSIBLE 
TO HAVE A WRITING DESK. 




(14" DEEP) 



A PLANNING GRID OF FOUR FEET WILL YIELD 
A 10 X 10 FEET (9-6" x 9'-6" CLEAR 
DIMENSION) EXAM ROOM IF WINDOW MULUONS 
FALL ON TWO-FOOT-CENTERS, OR IF THE 
EXTERIOR WALL OTHERWISE ACCOMMODATES 
THIS VARIATION FROM THE MORE STANDARD 
8 X 12 FEET EXAM ROOM. 



9-6" 




(14" DEEP) 



CUBICLE DRAPE 
AROUND DOOR 
PROVIDES PRIVACY 



EXAM ROOM 



EXAM ROOM 



Figure 3-40. Alternative layouts and sizes for examination rooms. (Design: Jain Malkin Inc.) 



(Figure 3-8). As an alternate, one may place a cubicle 
drape around the door as in Figure 3-40. 

With certain medical specialties, for example, ear, nose, 
and throat (ENT) or orthopedics, patients rarely undress, 
or if they do so, they primarily undress just to the waist, so 
private dressing cubicles would not be a priority in these 
practices. 

It should be noted that cubicle drape fabric is specially 
fabricated for this purpose. It is 72 inches wide, has two 
"good" sides in terms of pattern and appearance, and can 
be washed at a temperature of 160 degrees Fahrenheit. 
Manufacturers include Maharam, Carnegie, DesignTex, 
and Momentum. 



Position of Exam Table 

The second functional consideration is the position of the 
examining table. The foot or stirrup end of the table should 
be angled away from the door (Figure 3-41) as well as the 
wall , so that the doctor has access to all sides of the patient, 
and the patient is out of view of passersby in the corridor 
when the door is opened. Related to the position of the 
exam table is the placement of the wall-mounted diagnos- 
tic instrument panel (Figures 3-6, 3-39, 3-41 , and 3-42). 

The door to an exam room should be hinged so that it 
opens away from the wall (does not stack against the 
wall). While this might seem awkward in most rooms, it is 
desirable in a medical exam room because it shields the 



Family Practice 55 





. : l 1. ■ 

■ * " t 

) 


_ 




Figure 3-41. Standard examination room. {Design: Jain Malkin Inc.; 
Photographer: Robinson/Ward.) 



Figure 3-42. Primary-care examination room with lowered desk surface for physician. {Architecture: Moon 
Mayoras Architects, San Diego, CA; Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.) 



patient from corridor traffic, should the door be opened 
accidentally, and gives the patient more privacy when 
dressing, since one has to walk around the open door to 
enter the room. It should be noted that the ADA requires 
1 8 inches of clear space on the pull side of the door, mak- 
ing it awkward to open the door to shield the patient in a 
7-foot-6-inch-wide room as it puts the door almost in the 
center of the room (Figure 3-38). 

Cabinets 

The sink cabinet may be located either on the foot wall 
opposite the door or on the long wall, to the right, as one 



enters the room. Either location is functional in a room in 
which pelvic or proctologic examinations are done. 

The sink cabinet need have only a small sink (a 12- 
x 12-inch stainless steel bar sink works well), as instru- 
ments will be washed at the nurse station or lab. In addi- 
tion, the sink should have a single-lever faucet. The sink 
cabinet should be a minimum of 48 inches long, 24 inch- 
es deep, and 34 inches high. If space permits, it might 
have a built-in compartment for trash with a hinged "trash 
slot" cut into the face of the cabinet door (Figure 3-42). 
Each exam room needs a container for general waste as 
well as biohazardous waste. 



56 Practice of Medicine: Primary Care 



An upper cabinet may be provided (48 inches long, 14 
inches deep, 36 inches high), over the base cabinet, for 
storage of disposable gowns, sheets, and other paper 
products (Figure 3-38). Shallow drawers in the base cab- 
inet store instruments, syringes, surgical gloves, dress- 
ings, tongue depressors, and the like. Paper towel and liq- 
uid soap dispensers should be mounted on the wall near 
the sink, as well as sharps containers and a rack for hold- 
ing boxes of gloves (Figure 3-43). These items are often 
provided by the paper or supply vendors who service the 
units but, if the designer does not oversee the installation, 
they may be placed with no regard for the aesthetics of 
the room. 

Obstetricians and gynecologists often like to warm 
their specula prior to examinations. For this purpose, an 
electrical outlet may be provided in the drawer in which 
the specula are stored. The more expensive pelvic exam- 
ination tables have a built-in warmer. 

A small wall-hung writing shelf may be provided in an 
exam room to enable the physician to complete most 
examinations in the exam room without returning to the 
consultation room. The prefabricated unit in Figure 3-44 
can be customized to house a laptop computer. It has 
storage for a chart, a place for prescription pads, and a 
tackable surface, and it is self-closing. If the sink cabinet 
is located on the long wall or the foot wall, the countertop 
can be extended, and lowered, from 34 inches to 30 inch- 
es, to serve as a writing desk (Figures 3-36 and 3-42). A 
rolling stool that stores under the "desk," when not in use, 
should be provided for the physician. 

The patient may sit on the exam table (Figure 3-42) or 
on a guest chair while the physician is taking a patient 
history or writing a diagnosis. Over time, the use of laptop 
computers or fully loaded PC tablets (Figures 3-29a and 
3-29b) will become more common and may influence the 
character of the physician/patient interface. 

The cabinetry should be clad with plastic laminate, 
rather than painted. The additional cost when fabricating 
cabinets is minimal, and well worth it, when one consid- 
ers the abuse of the painted surfaces plus the inconven- 
ience, and cost, of repainting. 





HIGHIHH 






-MM 

ill 


J2^M*la*(&5ifi Swat 




r- , fr " "** *™si» 






ssisn — — ~_- t 




Umm ^T 


'II 

M 




LH^j^u 


1 


_ijH 




Figure 3-43. Plexiglas glove box holder. 
(Photo courtesy: Custom Comfort, Inc., 
Orlando, FL.) 



Figure 3-44. Wall-mounted fold-down physician's writing desk. 
(Photo courtesy: Peter Pepper Products, Inc., Compton, CA.) 



Windows 

There is controversy over the benefit of windows in exam 
rooms. There is no need for natural light in an exam room 
for most specialties (it is recommended for dermatology 
exam rooms, however), so the inclusion of windows 
would be either a matter of the physician's preference or 
a given of the building's architecture. However, natural 
light makes the room more pleasant, especially if the 
patient is kept waiting. If present, the glass should start at 
a height sufficient (generally 42 inches) to afford the 
patient a measure of privacy. 

Gray glass is superior to bronze since the latter casts 
an unhealthy tint on a patient's skin. Horizontal slat wood- 
en blinds or vertical blinds are particularly well suited to 
windows in exam rooms, as the slats can be tilted to pro- 
vide privacy without cutting off the light or view entirely. 

Too many windows in a medical building can make it dif- 
ficult to lay out the rooms efficiently unless one wishes to 
have partitions that terminate in the middle of a window, 
instead of at a wall or a mullion. This is particularly common 



Family Practice 57 



when the architect who designed the building was not 
familiar with medical space planning, and a window mod- 
ule was designed that was not compatible with the size of 
the rooms in a medical office — basically a 4-foot module. 

Electrical Requirements 

Three grounded duplex electrical outlets should be pro- 
vided in an examination room — one above the cabinet 
countertop, one at the foot of the table, and one near the 
head of the table. Except for the outlet over the counter- 
top, which would run horizontally at a height of 42 inch- 
es, the other outlets may be a standard 15-inch height. 
Some physicians use a wall-mounted diagnostic instru- 
ment panel that would be positioned on the long wall, at 
approximately 60-inch height, near the head of the exam 
table (Figures 3-39, 3-41 , and 3-42). It requires an elec- 
trical outlet that may be placed low on the wall, or high, 
depending on how much electrical cord one wants visi- 
ble. Rooms used for ophthalmic or ENT examinations 
have special electrical requirements, to be discussed in 
Chapter 4. 

Certain exam rooms, such as pediatric or orthopedic 
exam rooms, often require only two electrical outlets, one 
over the countertop and the other near the foot of the exam 
table. Outlets in a pediatric exam room must be carefully 
guarded and located where a child cannot reach them. 

Some examinations, such as OB-GYN exams, require 
an additional light source, which is usually a high-intensity 
quartz halogen lamp on a mobile floor stand. Some practi- 
tioners like a ceiling-mounted high-intensity lamp at the 
foot of the exam table. This requires support in the ceiling 
for mounting it (Figure 3-42). A halogen light may also be 
bracketed to the end of the exam table (Figure 3-39). 

It may be necessary to shield a specialized exam room 
(one used for electrocardiograph machinery, for example) 
against electrical interference from surrounding medical 
offices or equipment, although this is increasingly rare 
with current equipment. 

Exam Table 

The standard exam table is 27 inches widex54 inches 
long plus stirrups and pull-out footrest (Figures 3-39 and 



3-42) if it is to be used for pelvic or urologic examinations. 
If not used for these purposes, the table will have a pull- 
out foot board that extends the length of the table to about 
6 feet. There are specialized tables for cystoscopic (uro- 
logical) examinations (Figure 4-158). 

The examining room, as described above, will be suit- 
able for most physicians, but some medical specialties 
require modifications, and these are discussed in future 
chapters. Most notably, orthopedic surgeons use an 80- 
inch-long exam table, which is sometimes placed against 
a wall. Pediatricians also often place their exam tables 
against the wall. 

The combination consultation room and examination 
room popularized some years ago by the Mayo Clinic 
(Figure 3-37) is an alternative that has a place in some 
practices. The Mayo brothers were pioneers in exploring 
options for the design of exam rooms to enhance produc- 
tivity. Whatever the design of the exam room, the formula 
for a productive and efficient office is in the relationship 
between exam rooms, consultation rooms, nurse sta- 
tions, and support areas. 



Treatment/Minor Surgery 

Each family practice or general practice suite will have a 
minor surgery or procedure room (Figure 3-45). It is some- 
times called a treatment room. It is a large exam room 
(usually 12x12 feet) that serves a variety of purposes. It 
may be used as a cast room, in which case a plaster trap 
should be provided in the sink, and cabinets should con- 
tain a bin for plaster and for the remains of casts that have 
been removed (see Chapter 4, Orthopedic Surgery). 

It may be used as an ECG room, as an operating room 
for minor surgical procedures using local anesthetics, and 
as an emergency exam room for accident cases. In treat- 
ing emergencies, the physician may need one or more 
aides in the room plus certain medical equipment not 
usually stored in other exam rooms. Add to that the rela- 
tives who accompany the patient and frequently wish to 
remain in the treatment room, and the need for an over- 
sized, multipurpose exam room becomes clear. 



58 Practice of Medicine: Primary Care 



A minor surgery room should have a 10- to 12-foot 
length of upper and lower cabinets — one full wall of built- 
ins. Usually, this room will have a ceiling-mounted surgi- 
cal light over the treatment table, in addition to standard 
fluorescent lighting (Figure 3-45). Proper illumination is 
mandatory for this room. 

If the suite is so situated within the layout of the med- 
ical building as to make possible a direct entrance to the 
minor surgery room, it is desirable. Accident cases or 
those with contagious diseases do not have to walk 
through the waiting room if they can enter the minor sur- 
gery room directly. This would be an unmarked door in the 
public corridor of the medical building provided with a 
buzzer, or the door might simply state Emergency 
Entrance — Ring Bell for Service. 

The receptionist taking the emergency call would ask 
the patient to go to the door marked Emergency Entrance 
and ring the bell. 



Consultation Room 

This room functions as a private office for the most part, 
but some physicians do consult with patients here. 
Routine consultation can be handled in a well-designed 
exam room, saving the physician the trouble of continu- 
ally returning to his or her private office with each 
patient. 

Certain physicians (e.g., internists, oncologists) 
spend a good deal of time interviewing the patient 
on the initial visit. In such cases, physicians may feel 
that the consultation room provides a more conducive 
atmosphere for establishing the relationship or for dis- 
cussing serious illnesses. Surgeons also tend to use 
their private offices for consultation with patients, but 
this remains a matter of individual preference for each 
physician. 

The consultation room is also used by the physician for 
reading, returning phone calls, dictating notes, or just 
relaxing. The minimum size for this room is 10X12 feet, 
but 12x12 feet is better. The room must accommodate a 
desk with computer, credenza, bookshelves for the doc- 




Figure 3-45. Minor surgery room. {Design: Jain Malkin Inc.; Photographer: 
John Christian.) 



Family Practice 59 



Figure 3-46. Diplomas, attractively framed. 
{Design: Jain Malkin Inc.; Photographer: 
Michael Denny.) 





O 



¥? 





Figure 3-47. Shared physician office. Montefiore Medical Center in the Bronx. (Architecture and interior design: 
Guenther Petrarca, New York, NY; Photographer: Lynn Massimo.) 



tor's library, two guest chairs, a coat closet (optional), and 
perhaps a private bathroom. 

The room should be furnished like a living room or 
study with cut pile carpet, textured wallcoverings, comfort- 
able furniture, and artwork. If the doctor has a hobby that 
lends itself to expression in room decor, this is the one 
room in the suite that can be highly personalized. Family 
photos, armed forces honors, and personal memorabilia 
humanize the doctor's image and provide a clue to him or 
her as a person, apart from the medical practice. 

The physician's diplomas and credentials should be 
nicely framed and displayed in the consultation room. If 
grouped artistically (Figure 3-46), they can complement 
the room's decor. 

A consultation room should have natural light if possi- 
ble. In addition, table lamps or indirect lighting may add to 
the room's homelike ambience. It is desirable to locate the 
consultation room at the rear of the suite to give the 
physician more privacy and to ensure that patients do not 
pass it on their way to the examining room. Still, some 
assertive patients find their way to the consultation room 
uninvited and unannounced. 

It may be possible to locate an outdoor exit in the pri- 
vate office. The physician may thus enter or leave without 
being seen by patients. If such a door is not possible, then 
a private rear entrance to the suite, as previously dis- 
cussed, is mandatory. 

In certain suites, such as pediatrics, the consultation 
room is used so minimally that several physicians may 
share one. Their combined medical library would be 
stored here, and each doctor would have a small desk 
and telephone (see Figure 3-47). 

At the other extreme, a physician will occasionally 
request a consultation room with a sofa large enough to 
sleep on, a table with reading lamp, a refrigerator, and 
bathroom with shower, in addition to the usual compo- 
nents of a private office. Such an office may serve a car- 
diac surgeon who, due to many emergency surgeries, 
may have to spend the night at the office (if it is near the 
hospital) or just catch up on sleep during the day between 
surgeries. 



60 Practice of Medicine: Primary Care 




Figure 3-48. Nurse station. (Design: Jain Malkin Inc.; Photographer: 
John Christian.) 



Figure 3-49. Nurse station, pediatric community clinic. (Interior design: Jain Malkin 
Inc.; Photographer: Steve McClelland.) 



Nurse Station and Laboratory 

The nurse station is an area where the doctor's nurses or 
assistants perform a variety of tasks such as weighing 
patients, sterilizing instruments, dispensing drug sam- 
ples, giving injections, taking a patient's temperature, per- 
forming routine lab tests, communicating with patients by 



telephone, or handling office paperwork (Figures 3-48 
and 3-49). 

The nurse station may be only a 6-foot length of coun- 
tertop (with cabinets below and above) recessed in a 
niche in the corridor (Figure 3-52), or it may be an 8-x 12- 
foot room or area adjacent to the exam rooms (Figure 
3-2). The size of the nurse station depends on the num- 



Family Practice 61 




Figure 3-50. Pneumatic blood draw chair. 
(Photo courtesy: Custom Comfort, Inc., 
Orlando, FL) 



ber of nurses or aides who will use it, the type of medical 
practice, and the functions to be performed by those indi- 
viduals. The nurse station in Figure 3-35 offers physicians 
maximum access to nurses and numerous stand-up- 
height writing shelves. 

The number of physician extenders can be estimated 
on the basis of each doctor requiring one or two assis- 
tants, depending on whether the practice is a high-vol- 
ume specialty. This person, depending on training, may 
assist the physician in the exam room or may actually 
perform certain examinations. Obstetricians and gyne- 
cologists have been using nurse practitioners in this 
expanded role for routine pelvic and gynecologic exam- 
inations. Since OB-GYN is a very high-volume special- 
ty, the use of nurse practitioners saves the physician 
time on routine examinations and permits him or her to 
concentrate on patients with more demanding medical 
problems. 

Therefore, the nurse station in an OB-GYN suite must 
be large enough to accommodate the nurse practitioners 
and other aides who need a knee space for sitting down 
and writing notes, one or two scales (all OB-GYN patients 
are weighed each visit), with a writing shelf nearby. 
Sometimes scales are recessed into the floor, if practical, 
in terms of cost and construction parameters. This recess 
in the concrete slab can be carpeted with the adjacent 
floor carpet. An area of approximately 24 inches should 
be allowed for each scale. This is not the size of the 
recess but the floor space necessary to accommodate a 
standard medical scale with balance rod. 

There is an advantage to locating the nurse station 
near the front of the suite in a small office (under 1500 
square feet). The nurse has easy access to patients as he 
or she leads them from the waiting room to the exam 
room, and the nurse can cover for business office staff 
when they are momentarily away from their desks. In larg- 
er suites, each doctor may have a nurse or medical assis- 
tant working from a nurse station convenient to his or her 
pod of exam rooms (see Figures 3-2 and 3-52). 

In some medical offices, the nurse station is combined 
with the laboratory. In otolaryngology (ENT), for example, 
this is true since few lab tests are performed in the office. 



The nurse station/lab would be used for preparing throat 
cultures and for cleanup of instruments in the sink or for 
sterilizing instruments. With the widespread use of dis- 
posable syringes, gowns, sheets, and even many exami- 
nation instruments, relatively few items have to be 
washed or sterilized. 

In an OB-GYN practice, the laboratory would usually 
be a separate room because a good deal of lab work is 
generated in the suite. Each patient supplies a urine sam- 
ple for analysis, which is performed in the lab, and each 
patient having a pelvic exam and Pap smear will have a 
tissue culture that will have to be prepared for sending to 
a cytology lab. 

A number of other routine tests would be performed 
within the lab, plus many gynecologists do D&Cs (dilation 
and curettage), terminations of pregnancy, and other 
types of minor surgery procedures in a well-equipped 
minor surgery room in the office. These procedures can 
be messy and require an adequate area for cleanup and 
a good-sized nurse station, plus lab support facilities. 

A lab should have a double-compartment sink, a knee 
space area for a microscope, and a full-size refrigerator, if 
necessary (otherwise an undercounter one). It may also 
have a blood drawing station with a specialized blood draw 
chair (Figures 3-50 and 5-79) as standard tablet-arm 
chairs are not functional for this purpose. It is advisable to 
shield the patient whose blood is being drawn from the 
sight of other patients, who often become faint upon 
observing the procedure. The countertop will have a cen- 
trifuge for spinning down blood before sending it out to a 
lab and may have (if more lab work is done within the 
suite) a countertop analyzer. Refer to Chapter 5 for photos 
of clinical analyzers. 

It is desirable to have at least one toilet room adjacent 
to the lab so that a specimen pass-through door in the 
wall can give the lab technician access to urine speci- 
mens without leaving the lab (see Figure 3-21). The read- 
er is referred to Chapter 5 for more detailed specifications 
of a small laboratory and to the Appendix for a diagram of 
a specimen pass-through. 

The nurse station of an orthopedic surgery suite would 
be of minimal size since there are no lab tests per- 



62 Practice of Medicine: Primary Care 



formed, and no blood is drawn. The supplies needed for 
examinations or for making or removing casts would be 
stored in the respective rooms, and very little would have 
to be carried into a room for a procedure. In fact, ortho- 
pedic offices have tech workstations rather than nurse 
stations. 

By contrast, a family practice or G.P. suite would have 
a large nurse station. Since such a wide variety of med- 
ical procedures are performed and there is such a wide 
range of patients, it would be impractical to store in 
each exam room all the supplies one might need. 
Therefore, the nurse prepares the exam room with any 
special supplies, injections, dressings, and instruments 
that she anticipates will be required. A good many of 
these items will be stored in the nurse station, and each 
nurse station might have its own autoclave for steriliza- 
tion of instruments. In addition, the nurse might give 
allergy or other injections at the nurse station; blood 
might be drawn for tests to be done in the suite's own 
lab or sent out for processing; patients are weighed 
at each visit; and many other routine tasks are carried 
out here. 

A nurse station should always have a sink and often 
has an undercounter refrigerator and a knee-space work 
area with telephone (Figures 3-47 and 3-48). Most nurse 
stations have a scale space, with a nearby shelf, for 
recording the weight in the patient's chart. The reader is 
referred to Chapter 4 for nurse station requirements for 
each medical specialty. 



under certain conditions, for example, in rural areas 
where an independent lab may not be available, may 
physicians own a lab. Otherwise, financial interest in a lab, 
or other ancillary services, is viewed as a potential conflict 
of interest. 

It is estimated that today fewer than 1 percent of med- 
ical practices do lab work in house as CLIA (Clinical 
Laboratory Improvement Act), federal legislation enacted 
in 1988, imposes a level of compliance that results in high 
overhead and — with the decrease in reimbursement — it 
becomes a drain, rather than an economic incentive. 
Also, under managed care, a patient's insurance may dic- 
tate what lab must be used. 

CLIA Compliance 

Lab tests physicians may commonly do in their offices — 
and are allowed to do without CLIA compliance (although 
they still need to register with CLIA) — are what are referred 
to as "waived tests," something equivalent to the kinds of 
self-tests one could purchase at a pharmacy. These include 
dipstick urine tests for pregnancy or diabetes. 

Physicians who elect to do what are called "nonwaived" 
tests in the office would come under CLIA regulations. The 
most commonly performed tests include blood counts, glu- 
cose tolerance tests, kidney and liver function tests, and 
cholesterol testing or a full lipid panel. This work would 
require benchtop hematology and chemistry analyzers. 
See Chapter 5 for photos of automated analyzers and 
more detailed information about laboratories. 



Legislation Affecting In-House Labs 

Regarding the laboratory, the physician decides whether 
to do lab tests within the office or send the work out. 
Some do not even like to draw blood in their office, pre- 
ferring to send the patient to a lab, if one is conveniently 
located in the medical building. 

Stark Legislation 

In the past, physicians may have had a financial interest 
in a lab to which they referred their patients, but with the 
federal Stark legislation enacted a number of years ago, 
this is rare. Only under the "safe harbor" provision, and 



Drug Testing 

Large family practice suites and clinical laboratories may 
wish to do testing for drugs as part of employment- 
required physical exams. A toilet room designed for this 
purpose is discussed in Chapter 5. 

OSHA Issues 

The Occupational Safety and Health Administration 
(OSHA) of the U.S. Department of Labor protects workers 
from occupational hazards and risks. It publishes guide- 
lines, standards, and regulations governing a multitude of 
settings, products, and situations, most of which have to 



Family Practice 63 




Figure 3-51. Opti-Klens I eyewash 
faucet diverter. {Photo courtesy: Desert 
Assembly, Inc., Henderson, NV.) 



do with processes and procedures, none of which come 
under the purview of the architect or designer. OSHA also 
evaluates products such as sharps disposal containers to 
determine if they meet OSHA standards. Periodically, 
worksites, including medical and dental offices, may be 
visited by OSHA inspectors. Designers should be aware 
of the following issues: 

1 . Personal-use or edible items cannot be stored in the 
same refrigerator as blood or tissue samples. 
However, according to OSHA, refrigerators containing 
medications or other substances stored for medical 
procedures (e.g., challenge solutions for glucose tol- 
erance tests) are not subject to the restriction. 

2. An eyewash diverter valve device mounted to a faucet 
is required in any workplace where the eyes of the 
employee may be exposed to injurious materials. In 
OSHA interpretations letters, it is not clear where, in a 
medical or dental office, they might be required. 
However, a large primary-care office might have one; 
urgent-care clinics (for walk-in patients) and ophthal- 
mologists often have one for patients. The device 
must meet American National Standards Institute 
(ANSI) Z358.1-1990, as does the Opti-Klens® unit in 
Figure 3-51. 

3. In offices where staff are exposed to bloodborne 
pathogens, staff should remove their lab coats prior to 
leaving the suite. The idea is to not carry home organ- 
isms on one's clothing. Although not required by 
OSHA in physicians' or dentists' offices, depending on 
the specialty, the practitioner may wish to provide a 
locker room and change area for staff. Disposable 
items with bodily fluids must be red-bagged and 
labeled "biohazardous waste" and collected by a serv- 
ice. A biohazardous storage room, usually near the 
staff entrance to the suite, will house the waste until it 
is picked up. It can also be stored in a soiled utility 
room. [Note: Some suite plans in this book lack this 
room as it was not a requirement when these suites 
were designed.] 



4. Occupational exposure to bloodborne pathogens 
including hepatitis B and C viruses as well as human 
immunodeficiency virus (HIV) poses great risk to 
healthcare workers. Needle-stick injuries are a serious 
hazard and OSHA has researched every aspect of this 
problem and published numerous standards and doc- 
uments relating to how injuries occur and how they 
can be reduced. Standards for selecting the safest 
sharps disposal container and suggestions for training 
staff are covered in the Occupational Exposure to 
Bloodborne Pathogens Standard. 

Placement of Sharps Disposal Containers 

It is of interest to note that one of the three factors most 
often related to sharps injuries is inappropriate placement 
of the sharps container. It should be visible and placed at 
an arm's reach and below eye level at the point of use. 
According to OSHA, the fixture should be below the eye 
level of 95 percent of adult female workers, which results 
in an optimal installation range of 56 to 52 inches at a 
standing workstation and 42 to 38 inches for a seated 
workstation. 

A word of warning: When a physician's office staff con- 
veys to the designer OSHA standards and regulations 
that must be met, it is advisable to check it out by calling 
OSHA. In the author's experience, much of the time, 
either no regulation exists or, if it does, its effect on the 
built environment has been misunderstood. The problem 
is that individual OSHA inspectors may cite a facility for a 
perceived infraction that cannot be found in a literal read- 
ing of the OSHA text. In addition, each state has its own 
OSHA interpretations. Physicians' office staffs are right to 
treat employee safety issues seriously and to want to 
address them to the letter of the law since the liability and 
risks are substantial for noncompliance. However, much 
of the compliance deals with staff training, keeping pro- 
cedure manuals updated, and making certain the staff 
actively follow the procedures they have outlined to pro- 
tect patients and employees. In that regard, an excellent 
resource for OSHA compliance training, consulting, and 
compliance products is HPTC in Plymouth, Michigan 
(www.hptcinc.com). 



64 Practice of Medicine: Primary Care 



Other Support Services 

X-Ray Room 

This discussion will focus on the one-room X-ray unit that 
can be found in a family practice or internal medicine 
suite (Figure 3-52). Rather simple radiographic examina- 
tions are performed here — films of extremities, chests, 
gallbladders, appendixes, and so forth. More complicated 
procedures will be performed in a radiologist's office. A 
large internal medicine practice might have a suite of radi- 
ographic rooms within its facility with a full-time radiologist 
on staff. But usually a patient who requires Gl (gastroin- 
testinal) studies, thyroid scans, computed tomography 
(CT) scans, radiation oncology therapy, or other special- 
ized or complicated diagnostic imaging procedures will be 
referred to a local hospital on an outpatient basis or to a 
nearby radiology clinic. 

A 10x1 4-foot room is adequate (not taking into 
account the dressing area and darkroom) for most X-ray 
machines used in a family practice or internal medicine 
office, although a slightly larger room would be more 
comfortable. Usually, a 9-foot ceiling height is required. 
There should be a place inside or outside the room for a 
patient to dress (ideally a 3-x4-foot alcove with a drapery 
or door for privacy), a control area for the technician, and 
a place to process the film. Although the equipment 
breaks down into components, it is advisable to provide a 
minimum 3-foot-wide door in this room for ease in moving 
the equipment. Although new imaging equipment is digi- 
tal and filmless, many physicians have existing equipment 
that is not and it is unlikely most will trade it in as long as 
it's still serviceable. Therefore, the discussion about film- 
less imaging will be confined to Chapter 5. 

The radiography room does not need a sink or prep 
area unless Gl studies are performed or contrast media 
are used, in which case a bathroom must be located 
close to the radiographic room (Figure 5-5). 

Two or more walls of an X-ray room will have to be 
shielded with lead to protect office occupants as well as 
passersby from radiation scatter. It is necessary to obtain 
a radiation physicist's report, which takes into account the 



type of equipment and the location of the room within the 
suite and within the medical office building, in order to 
know which walls must be shielded, the thickness of the 
lead, and the height of the lead panels. Frequently, the 
door to the room must also be lead-lined. Such a door is 
very heavy and must have a heavy-duty door closer. The 
control partition, if located within the room, must also be 
lead-lined. It is possible to buy prefabricated, lead-lined 
control partitions with glass viewing panels from X-ray 
supply houses. 

If the control area is located outside the X-ray room, 
there must be a lead-lined glass window to enable the 
operator to observe the patient at all times (Figure 4-122). 
The control area need not be large — 3 feet square is 
generally adequate. 

There are considerable variations in size of radiology 
equipment, power requirements, and other specifications 
from one manufacturer to another. Therefore, it is advis- 
able to obtain planning guides for each piece of equip- 
ment before proceeding. 

A valuable reference in designing radiology rooms is 
the catalog of radiology accessories marketed by each 
manufacturer. These catalogs are available online through 
the Internet and, in addition, some are available as print- 
ed catalogs as well. General Electric has a particularly 
good one, in which many items are pictured with dimen- 
sions and pertinent data. This will familiarize the designer 
with the numerous accessory items (cassette pass boxes, 
film illuminators, film dryers, automatic processors) that 
must be accommodated in a radiology room or suite. 

A lead-lined cassette pass box should be located in the 
wall between the darkroom and the radiography room. 
The pass box is used for passing exposed and unex- 
posed film back and forth between the rooms. 

The manufacturer's literature will specify utility require- 
ments and critical distances between equipment. 
Additional support is usually needed in the ceiling to sup- 
port the tube stand. The X-ray unit, if new, will often be 
supplied by a local distributor who will assist the design- 
er in locating the equipment in the room. Or, if the physi- 
cian is relocating existing equipment to a new office, it 
will usually be moved and reinstalled by a skilled techni- 



Family Practice 65 



cian who can offer assistance as to the equipment's 
requirements. 

Darkroom 

In the future, most radiographic equipment will be digital 
but, currently, most general practice and internal medi- 
cine clinics — if they do radiography — will have a dark- 
room. It should be set up with a "wet" and a "dry" side 
(Figure 10-78). A 6-x8-foot room is the minimum size, 
although, if designed to meet the ADA, and in view of the 
fact that a darkroom door always opens inward, the room 
would have to be larger. The room should have two full- 
width countertops either parallel to each other or at right 
angles. The wet side contains the sink, automatic proces- 
sor, and replenisher tanks, while the dry side is used for 
loading cassettes. A light-proof metal film storage bin 
should be located under the dry side of the counter. 
Ideally, the cassette pass box would be positioned in the 
wall close to the film storage bin. 

Sometimes a rack for storage of cassettes is provided. 
A floor drain must be located near the processor. One out- 
let should be provided over the counter on both the wet 
and the dry sides. An outlet is needed for the film storage 
bin as well. The processor requires only cold water if it is 
a recent model with an internal temperature control. 

Local codes normally require a vacuum breaker on pip- 
ing to darkroom tanks to prevent the chemical waste from 
backing up into the water supply. Also, acid-resistant pipe 
is recommended, since chemical waste is highly corrosive. 

The room must have an exhaust fan, and some codes 
require that the door have a light-proof louver ventilation 
panel. The darkroom door must be 36 inches wide and 
have a light seal. It should open inward, so that if some- 
one tries to enter while film is exposed, the technician 
inside the room can put a foot against the door to prevent 
it from opening. Some darkrooms have a red warning 
light that is activated when developing is in progress. 

The darkroom must have two sources of light. A 75- 
watt incandescent fixture, surface-mounted to the ceiling, 
will suffice for general illumination, but a safelight must be 
provided for working with exposed film. The safelight may 
be plugged into an outlet at 60 to 72 inches off the floor, 



and it can work by a pull chain or be wired into a wall 
switch. If the latter, the switch should be located away 
from the incandescent light switch so that the technician 
does not confuse them and hit the wrong one while the 
film is exposed. Any recessed light fixtures and the 
exhaust fan must have a light-sealed housing. 

Counters and cabinets in a darkroom may be at a 36- 
inch or 42-inch height, according to personal preference. If 
designed to meet the ADA, the countertop must not 
exceed the 34-inch height. There is no need for closed stor- 
age in the darkroom. All shelves should be open shelves. 

A small viewing area is required outside the procedure 
room, near the darkroom (Figure 4-1 24). This may consist 
of nothing more than a double-panel view box illuminator, 
either surface mounted to the wall or recessed (Figure 4- 
133). The X-ray technologist checks the films for resolu- 
tion and clarity before handing them to the physician for 
diagnosis. If the film is not good, the patient is still at 
hand, with little time lost in having to take the film again. 
In a larger X-ray suite of rooms, the viewing area will be 
larger, with several banks of film illuminators and a place 
for two or more persons to sit down. 

The film will be developed by an automatic film proces- 
sor which may be a small tabletop unit such as dentists, 
otolaryngologists, or plastic surgeons use, or a floor 
model that sits outside the darkroom in the tech work 
area (Figures 3-52 and 4-124) with a feed tray that fits 
through the wall into the darkroom (see Figure 5-25). The 
exposed film is fed into the processor from the darkroom 
and "daylights" (drops out after processing) into the tech 
work area. See Chapter 5 for more detail. The suite in 
Figure 4-127 is set up for digital radiography but still 
accommodates storage of old film files. 

Storage 

Medical offices should have a storage room at least 6 feet 
square with two or more walls of adjustable shelves for 
storage of office supplies, sterile supplies, pharmaceuti- 
cal items, housekeeping supplies, and cartons of toilet 
paper, hand towels, and facial tissue. If the office does not 
use a janitorial service, the vacuum cleaner and mop and 
pail would be stored here. 



66 Practice of Medicine: Primary Care 



Staff Lounge 

Any suite with more than two employees should have a 
staff lounge. The room need not be larger than 10X12 
feet with a built-in sink cabinet 6 to 8 feet in length, an 
undercounter refrigerator, microwave oven, garbage dis- 
posal, a small table and chairs, and possibly lockers for 
personal effects. Do not underestimate the countertop 
area required considering coffee maker, appliances, dish 
drying rack, and space for the box of dougnuts. 
Remember that a refrigerator with an ice maker will 
require a water line. A larger staff lounge might include a 
sofa where an employee can lie down as well as a full- 
size refrigerator. This is a private room where the staff 
may take coffee breaks or eat their lunch. A staff lounge 
is an amenity that pleases employees and makes their 
jobs a little more pleasant. Furthermore, one does not 
want staff eating food in the nurse station, in the lab, or at 
the reception desk. 



INTERNAL MEDICINE 

The practice of internal medicine is broad. It encompass- 
es subspecialties such as pulmonary disease, nephrolo- 
gy, oncology, hematology, gastroenterology, endocrinolo- 
gy, and cardiovascular disease — the major emphases. 
Before planning an internal medicine suite, it is important 
to analyze the physicians' respective specialties and 
practice schedules. Internists often function as general- 
practice primary-care physicians for adults, providing a 
full spectrum of care (generally excluding gynecological 
examinations), or they may practice only their subspe- 
cialty such as cardiology, pulmonology, or endocrinology. 
The combinations of subspecialties in a group practice 
will obviously influence the program of rooms. Table 3-2 
provides a general idea of a typical complement of rooms 
and Figure 3-52 shows the relationship of rooms. 

With such a broad range of areas of expertise, it 
is common for internists to practice in groups rather than 
as solo practitioners. A designer must also understand 
the structure of a physician's workday. Physicians tend to 
visit their hospitalized patients in the morning, before 









Table 3-2. 










Analysis of Program. 
Internal Medicine 






No. of Physicians: 




2 




3 




4 


Consultation 


2@ 


12X12=288 


3@ 


12X12=432 


4@ 


12X12=576 


Exam Rooms 


6@ 


8x12=576 


8@ 


8X12=768 


10® 


8x12=960 


Waiting Room 




14X18=252 




20X20=400 




20x24=480 


Business Office 




16X20=320 




20X20=400 




24x26=624 


Office Manager 




10X12=120 




10X12=120 




10X12=120 


Nurse Stations 


2@ 


8X8=128 


3@ 


8X8=192 


3@ 


8X8=192 


Toilets 


2@ 


7X8=112 


3@ 


7x8=168 


4@ 


7X8=224 


Storage 




6X8=48 




6X8=48 




8X10=80 


Flex Sig. Room a 




12X18=216 




12X18=216 




12X18=216 


Staff Lounge 




10X12=120 




12X12=144 




12X14=168 


Laboratory* 




10X12=120 




10X12=120 




10X14=140 


ECGATreadmill 




10X12=120 




10X12=120 




10X12=120 


Pulmonary 




— 




(Optional) 




14X16=224 


Function Testing 














Radiology c 




— 




12x25=300 




12X25=300 


Subtotal 




2420 ft 2 




3428 ft 2 




4424 ft 2 


20% Circulation 




484 




685 




884 


Total 




2904 ft 2 




4113 ft 2 




5308 ft 2 



"Includes workroom and toilet (flexible sigmoidoscopy room); used for various types of special procedures. 
'Includes lab, sub-waiting, and blood draw. Optional: Patients may be sent out for blood draw. 
Includes darkroom, control, film filing, radiology room, and viewing area. 



office hours. Office hours typically begin at 9 a.m. and con- 
tinue to 12 noon. Medical offices are usually closed from 
noon to 2 p.m. and open again from 2 to 5 p.m. Surgeons 
try to do the bulk of their surgery in the morning and 
reserve the afternoon for office visits by patients. 

In a five-person practice, for example, physicians' sched- 
ules will usually be arranged so that no more than three are 
in the office at any one time (Figure 3-53). This negates the 
need for each of the five to have the use of exam rooms all 
at the same time. By efficiently coordinating their sched- 
ules, the group can function well in less space, without sac- 
rificing income or service to patients. One doctor may have 
a day off, while a second may be seeing patients at a satel- 
lite office, and a third may be seeing patients at the hospi- 
tal, leaving the other two in our hypothetical group of five in 



Internal Medicine 67 



HTZKMA.I- MEDICINE. 




stantial number of tests are to be done within the suite, a 
12-x 12-foot minimum size lab should be set up. The 
reader is referred to Chapter 5, Small Laboratory, for fur- 
ther details. Remember, however, the previous comments 
about CLIA regulations and how few physicians currently 
do lab work in their offices. 

An internist needs three exam rooms or five for each 
two physicians, provided there is a procedure room that 
can also be used. Ten exam rooms should suffice for a 
group of five physicians, allowing that at least one person 
is absent at any time and a second person may be absent 
for certain periods of the day. 

A small X-ray room should be provided for chest films. 
Gallbladder and gastrointestinal studies are referred to a 
radiologist or, as appropriate, are performed in an 
endoscopy suite, discussed later in this chapter. Refer to 
Family Practice for details of the X-ray suite. 

A large storage room may be needed for storing special- 
ized, seldom used equipment and for storing X-ray films. 



Figure 3-52. Schematic diagram of an internal medicine suite. 



Electrocardiograph (ECG) Room 



the primary office. At a busier point in the day, schedules 
may be arranged so that three or four of the internists are in 
the primary office seeing patients. 

Internal medicine is a medium-volume practice. It is 
based on diagnosis, which requires long history-taking 
interviews by the physician and sometimes a complicated 
battery of tests. The internist, being primarily a diagnosti- 
cian, spends a good deal of time with a patient. However, 
follow-up visits may be considerably shorter, so overall, a 
well-organized, efficient practice can process a fairly high 
number of patients each day. 

Some internists prefer to do the initial interview in the 
consultation room, whereas others find it more efficient to 
do it in the exam room. If the consultation room is used, it 
should be large — 12X12 feet — with comfortable seating. 

There is a lot of lab work associated with internal med- 
icine, and one must determine which tests are to be done 
within the suite and which are to be sent out. If a sub- 



A standard exam room (8X12 feet) can be used for ECG 
studies. Some physicians dedicate a special room to this 
function, while others feel that dedicated rooms result in 
a loss of flexibility. Since the equipment is portable, it can 
be moved from room to room as needed (Figure 3-54). A 
monitoring unit on a mobile cart is brought to the patient 
and electrodes attached to wires on the machine are 
placed on the patient's chest, leg, and wrist. The patient 
lies on a physical therapy-type table (or exam table) for 
this procedure. The instrument records the changes in 
electrical potential occurring during the heartbeat by 
imaging the vibrations and producing a printout — the 
electrocardiogram — which is then interpreted by the 
internist. This test is often performed by a nurse or aide. 
This type of ECG (where the patient lies supine) is 
called static. By contrast, a dynamic ECG involves an 
active patient whose heartbeat is monitored while he or 
she is walking on a motorized treadmill that is hardwired 
to the ECG machine and monitor, which control the ele- 



68 Practice of Medicine: Primary Care 




ENTRY 



INTERNAL MEDICINE 



7245SF 

Figure 3-53. Space plan for internal medicine, 7245 square feet. {Design: Jain Malkin Inc.) 



Internal Medicine 69 




Figure 3-54. Portable electrocardio- 
gram machine Eclipse 850. (Photo 
courtesy: © 1999 Spacelabs Burdick, 
Inc., Deerfield, Wl. Reproduced with 
permission.) 



vation and speed of the treadmill (Figure 3-55). One can 
program the remote control for the desired protocol. The 
treadmill is not easy to move around, so if dynamic ECGs 
are done, it is better to locate the equipment in one room 
and leave it there. Space for a "crash" cart with defibrilla- 
tor and portable oxygen is required wherever stress test- 
ing is done (Figure 3-56). In addition, a treadmill room 
also requires an exam table where the patient can lie 
down during the recovery phase. Working to maximum 
exertion can cause dizziness or nausea. In positioning 
the treadmill, there needs to be a wall in front of the 
patient for a "perceived exertion" chart, and the exam 
table must be near the treadmill in case the patient feels 
light-headed or unstable. The physician and tech need 




ready access to the right side of the patient to quickly 
replace an electrode that might have fallen off if the 
patient starts to perspire profusely. A cardiologist is 
always present during a treadmill test although he or she 
may not remain in the room for the entire test period. 

An ECG room without a treadmill can be the size of a 
standard exam room (8X12 feet) with space for a 2-X6- 
foot table for the patient to lie on, the portable monitoring 
equipment, and the standard exam room sink cabinet. The 
ECG machine stores enough paper for numerous tests 
and additional paper can be stored on the mobile cart and 
in a central storage room. The cart also stores the silver 
chloride disposable electrodes. Patients remove only their 
shirts or blouse for a static ECG procedure. 



Echocardiography 

Echocardiography is a noninvasive procedure that 
images the heart with ultrasound technology. The unit is 
portable and sits on a cart with a VCR and image printer 
(Figure 3-57). Sometimes the test is done while the 




Figure 3-55. Dynamic electrocardiogram. Quest Exercise Test System. 
[Photo courtesy: ©1999 Spacelabs Burdick, Inc., Deerfield, Wl. 
Reproduced with permission.) 



Figure 3-56. Cardiac defibrillator. (Photo courtesy: ©1999 Spacelabs 
Burdick, Inc., Deerfield, Wl. Reproduced with permission.) 



70 Practice of Medicine: Primary Care 



patient is on a treadmill (Figure 3-58). This can be per- 
formed in any standard examination room, but it requires 
absolute quiet. The patient lies on a flat table with the 
technician working from the patient's right side (Figure 
3-61). Room lights should be dimmable. 

The sonographer listens to sounds as they're coming 
toward and away from the probe; thus, extraneous noise 
makes it difficult to isolate the sounds although some 
sonographers wear headphones. "2-D Echo plus 
Doppler" means two-dimensional imaging (appears on a 
CRT) plus sound. It is important to eliminate glare on the 
CRT screen. Additionally, there is a need for storage of 
echo tapes, which are VHS cassettes. In the future, these 
will most likely be stored in a compressed digital format. 



Holter Monitoring 

Holter monitoring is a noninvasive procedure for recording 
cardiac activity on a 24-hour basis. Electrodes applied to 
the patient's chest are connected via lead wires to a 
Holter recording unit worn on the patient's belt. The data 
are recorded on microcassettes or standard-sized audio- 
cassettes, depending on the individual unit. In addition, 
the patient keeps a written diary of activities and events 
that is later correlated with the data on the tape. The 
patient returns to the office with the cassette, and the 
Holter tech then plays it on a Holter analyzer located at 
the workstation (Figure 3-59). A digital Holter recording 
device with built-in fax and modem allows Holter reports 





Figure 3-57. Echocardiography unit images the heart with 
ultrasound technology. SONOS Ultrasound Unit. {Photo 
courtesy: Agilent Technologies, Inc., Andover, MA.) 



Figure 3-58. Echocardiography examination room accommodates both static and dynamic (treadmill 
design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



imaging. (Interior 



Internal Medicine 71 




Figure 3-59. Holter analyzer. (Photo 
courtesy: ©1999 Spacelabs Burdick, 
Inc., Deerfield, Wl. Reproduced with 
permission.) 



to be sent by e-mail through the Internet to consulting 
physicians. Compatibility with Windows software provides 
composite screen formats for comparison and analysis of 
multiple cardiac data. 

The patient can be fitted for the monitoring equipment 
in any standard exam room. A physical therapy-type 
table is adequate, and the room should have some cabi- 
netry for storing supplies. The recorded cassettes can be 
stored in a storage room or at the tech's workstation. Note 
the relationship of test rooms in Figure 3-52 in the central 
core of the suite with a workstation for the tech who does 
echo, ECG, and Holter. The X-ray facility is also in the 
core with a sub-waiting area. 



12'-0" 



CRASH 
CART 



Vascular Lab 

Diagnostic studies of the blood vessels are performed in 
a vascular lab to detect blood clots, calcium buildup, fatty 
deposits, and so forth. A vascular lab might be set up with 
two rooms, one for carotid artery studies of the neck and 
one for studies of the extremities. A third room would be 
an office for the sonographers (Figure 3-60). 

A three-room suite as described above might handle 
approximately 14 to 20 cases per day. The time required 
with each patient varies, but the norm is a 20- to 30- 
minute patient history-taking and 40- to 60-minute test 
period, followed by a 15-minute period of calculation and 



12-0" 



DUPLEX 
SCANNER 



TREADMILL 

TREADMILL 

TELEMETRY 

UNIT 

CRT 
PRINTER 




EXTREMITIES ROOM 

VASCULAR LAB 



CAROTID OR 
CARDIAC ROOM 



STOR. 

OFFICE 

EC=EQUIPMENT CART 



576 SF 
Figure 3-60. Layout of vascular lab. (Design: Jain Malkin Inc.) 



72 Practice of Medicine: Primary Care 




Figure 3-61. Duplex Doppler ultrasonic imaging system. (Photo cour- 
tesy: ATL Ultrasound, Bothell, WA.) 



recording of data. Patients are usually gowned for tests, 
but procedures are noninvasive. 

The carotid room uses a duplex Doppler ultrasonic 
imaging system (Figure 3-61). As a point of information, 
power Doppler detects flow, duplex Doppler gives direc- 
tion of flow. A photo of the blood vessel can be produced, 
which can be placed in the patient's chart. The room also 
needs a desk for the sonographer and a sink cabinet, with 
storage above, for supplies and linen. A nice amenity to 
relax patients is a back-lit film transparency overhead of 
a view of nature (Figure 3-62). 

The extremities room uses a Stryker gurney cart that 
is mobile and allows for flexible positioning of the 
patient. There would be a treadmill alongside the tech's 
desk, with the treadmill telemetry unit on the desk. The 
duplex Doppler imaging scanner would be on one side 
of the bed. A resuscitation cart should be nearby. Other 
equipment can be stored on a mobile cart. The room 




Figure 3-62. Examination room for Doppler ultrasonic imaging features 
a back-lit film transparency of a view of nature overhead. {Interior 
design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



needs to be large enough to accommodate all this 
equipment (Figure 3-59). The same consideration with 
respect to dimming of room lights, quiet, and control of 
glare, hold true in a vascular lab, as they do for echocar- 
diography. 



Internal Medicine 73 




Figure 3-63. Handheld SonoSite 180 
portable ultrasound system. (Photo 
courtesy: SonoSite, Inc., Bothell, WA.) 



Figure 3-64. Portable SonoSite 180 
ultrasound system. [Photo courtesy: 
SonoSite, Inc., Bothell, WA.) 




i 



S 



H» 







Figure 3-65. Spirometer (the disposable flow sensor eliminates the 
need to sterilize between patients). (Photo courtesy: Welch Allyrf, 
Skaneates Falls, NY.) 



A portable ultrasound unit (Figures 3-63 and 3-64) that 
can be used in a vascular lab, in the operating room (OR), 
or in a physician's office for basic examinations is gaining 
in popularity. It shows the velocity of blood flow but at pres- 
ent is not duplex Doppler. This unit can be used for OB- 
GYN and other specialties such as cardiology. Exam pre- 
sets exist within the system. For example, if one plugs in a 
transvaginal probe, one will automatically access the 
exams appropriate for that transducer. Therefore, this 
instrument can be used in a variety of settings. 



Pulmonary Function Testing 

People with impaired lung functions are diagnosed in the 
pulmonary function lab. Pulmonary dysfunction may be 
acute or chronic. A patient recovering from pneumonia, 



for example, may need assessment and nebulizer treat- 
ment for a finite period but a patient with lung cancer or 
emphysema may need long-term evaluation and treat- 
ment for the remainder of his or her life. The composition 
of a pulmonary specialist's practice (age of patients, vol- 
ume of patients, proximity to a hospital's outpatient res- 
piratory therapy unit) will determine the extent, if any, to 
which inhalation therapy is done within the office. 

The spirometer, an instrument for measuring lung 
capacity (Figure 3-65), is the basic tool for pulmonary 
function studies. It, along with an analysis of blood gases 
and other clinical tests, helps the physician to evaluate 
the extent and nature of lung damage. A bronchodilator 
medication is often administered when spirometer studies 
are performed. 

Pulmonary function studies are noninvasive and can 
be performed quickly and inexpensively with computer 



74 Practice of Medicine: Primary Care 



calculations and comparisons to predicted normal values. 
These studies allow the physician to monitor the course 
of disease and to measure the effects of therapeutic inter- 
vention. 

Those seeking treatment may complain of shortness of 
breath, chronic cough, allergic manifestations, or dizzi- 
ness, or they may suffer from exposure to noxious dusts 
and fumes. Spirometry is generally included in annual 
routine health examinations, and it is required by law as 
part of the mandated screening program for people who 
are occupational^ exposed to hazardous fumes. 
Pulmonary function testing (also called PFT) provides a 
quantitative estimation of lung impairment. 

In this specialty, as in many others, declining reim- 
bursement in recent years has led physicians to make 
fewer investments in equipment and the additional space 
that may be required to accommodate it. Patients requir- 
ing more complicated tests would likely be referred to a 
hospital's outpatient pulmonary medicine. 

Most pulmonologists will have, in their offices, spirom- 
etry, ECG, and a method of measuring stress on the 
heart and lungs via a bike or treadmill hooked up to a 
sophisticated instrument that can measure and integrate 
several modalities. 

In recent years, spirometers have become miniaturized 
(Figure 3-66). With pneumotachometers, spirometers 
also measure the flow of expired air from the lungs. 
Diagnostic instruments may be combined in a micro- 
processor-based complete pulmonary function system 
(Figure 3-67) that measures lung volume, residual vol- 
ume, and diffusion (how gases pass into the blood). The 
metabolic analyzer (also called a metabolic "cart") meas- 
ures oxygen consumption and carbon dioxide production. 
Used with an exercise bike or a treadmill (Figure 3-68), it 
measures, through expired gases, the cardiopulmonary 
stress response to a graduated workload. It is also used 
in sports medicine facilities to train athletes and in rehab 
settings. It should be noted that arterial blood gases can 
be measured before, during, and after exercise testing. 

Although many pulmonologists would not have this 
equipment in their offices, one would find a body plethys- 
mograph or "body box" (Figure 3-69) in a large clinic set- 




Figure 3-66. Spirometer. (Photo courtesy: Medical Graphics 
Corporation, St. Paul, MN.) 




Figure 3-67. Pulmonary func- 
tion system. (Photo courtesy: 
Medical Graphics Corporation, 
St. Paul, MN.) 



Internal Medicine 75 




Figure 3-68. Metabolic analyzer and treadmill. {Photo courtesy: 
Medical Graphics Corporation, St. Paul, MN.) 



Figure 3-69. Plethysmograph for pulmonary function studies. {Photo 
courtesy: Medical Graphics Corporation, St. Paul, MN) 



ting. Along with complete pulmonary function capabilities, 
it measures thoracic lung volumes, airway resistance, 
and specific airway conductance. The technician sits out- 
side to observe and coach the patient who is seated 
inside the pressure-type "body box." The unit is approxi- 
mately 30x42 inches in size. 

Once the patient has been screened, the treatment 
phase would be called inhalation or respiratory therapy. 
The treatment generally consists of breathing mechani- 
cally pressurized air with medication. Currently, most 
patients' treatment can be managed by the use of nebu- 



lizers (inhalers) in the home, greatly reducing the use of 
the Bird intermittent positive-pressure breathing (IPPB) 
apparatus, which may require an outpatient visit, but can 
be rented for home use. Nebulizers are devices for 
aerosolizing metered doses of medications such as 
antibiotics and bronchodilators to the lungs to thin 
mucous secretions. The Bird IPPB machine would not be 
found in a physician's office but may be available in a 
large clinic or hospital; therefore, accommodation for this 
device will not be discussed here. The treatment might 
also consist of chest physiotherapy, in which a patient lies 



76 Practice of Medicine: Primary Care 



80-0 




INTERNAL MEDICINE 



2640 SF 

Figure 3-70. Space plan for internal medicine, 2640 square feet. (Design: Jain Malkin Inc.) 



on an angled bed and gravity flow drains different lobes 
of the lung. The therapist, after administering bron- 
chodilator medication, cups the patient's back, and the 
patient coughs up the mucous. 

Layout of Rooms 

There is no generally accepted standard layout for a pul- 
monary function lab because it depends largely on the 
specific pieces of equipment the practitioner has and 
whether cardiovascular screening will be included. In the 
last instance, it is called a cardiopulmonary lab. Figure 
3-70 shows a layout in which PFT and cardiopulmonary 
screening are performed. 



Typically, in such a combined setting, one might have 
an ergometer exercise bicycle, a treadmill, telemetry, a 
physical therapy-type table, ECG, spirometer, a crash 
cart with defibrillator and oxygen, and a desk for the 
tech. One may also find a computerized metabolic test- 
ing unit (Figure 3-67) used primarily with an exercise 
bike, occasionally with a treadmill, previously dis- 
cussed. 

The majority of pulmonologists do only diagnostic test- 
ing in their offices and then refer the patient to a hospital 
outpatient facility for inhalation therapy, if the use of in- 
home nebulizers is not adequate. But this is rare; most 
treatment can be provided in the home. 



Internal Medicine 77 



ENTRY 
TO 
CENTER FOR 
EXECUTIVE HEALTH 




1 WAITING 

2 RECEPTION 

3 WORKROOM 

4 JANITOR 

5 CLINICAL AREA 

6 OFFICE 

7 CONFERENCE/LOUNGE 

8 MASSAGE/FLEX/AEROBICS ROOM 

9 EXAM ROOM 
10 EYE/EAR ROOM 

1 SUB WAITING AREA 

12 BODY COMPOSITION 

13 BLOOD DRAW 

14 TREADMILL ROOM . 

15 FLEX/SIG ROOM 

16 MEN'S RESTROOM AND LOCKERS 

17 WOMEN'S RESTROOM AND LOCKERS 

18 SUSPENDED FABRIC PANELS, TYP. 



CENTER FOR EXECUTIVE HEALTH 

3484 SF 

Figure 3-71. Space plan for health assessment/screening clinic located at Scripps Memorial Hospital, La Jolla, CA. (Interior architecture and 
design: Jain Malkin Inc.) 



78 Practice of Medicine: Primary Care 



Accommodating the equipment shown in Figure 3-69 
requires considerable space as each patient needs priva- 
cy. If no partitions, screens, or curtains exist in the room, 
then it can only be used for one patient at a time, despite 
the inventory of equipment and diagnostic instrumenta- 
tion. 

Executive Health Centers. Sometimes a cardiopul- 
monary lab is part of an executive health screening facil- 
ity (Figure 3-71) and, if so, a high-profile "corporate" 
image may be appropriate. Windows are a desirable fea- 
ture in this room. A wood-look sheet vinyl floor is less 
institutional than vinyl composition tile and easy to main- 
tain, but carpet is also functional. 



Tech Work Areas 

In general, technicians are able to operate multiple 
types of diagnostic instruments since equipment is so 
automated it requires little training. Pulmonary function 
studies, and certainly respiratory therapy, require a 
trained respiratory therapist or nurse or an aide with 
PFT training. The volume of patients would determine 
staffing for ECG, Holter, echocardiography, and pul- 
monary testing. Techs often have workstations or desks 
in the room with the equipment so they can monitor the 
patient while doing desk work. Their work areas need to 
have space for supplies used in the procedures, a place 
to store microcassettes or tapes of patients' test results, 
and file cabinets for computer printouts of test results. In 
the future, compressed digital storage will become more 
common. 



Physicians' Consults 

Physicians are always present or nearby when stress 
testing is done. Therefore, consultation rooms for the car- 
diologists and pulmonologists associated with the testing 
should be adjacent to the test area. 



Sigmoidoscopy 

Both a general internal medicine physician who does not 
have a subspecialty in gastroenterology and a family 
practice physician would likely use a multipurpose proce- 
dure room for the occasional need to look at an 
unprepped colon. The patient would be given a Fleet 
enema prior to the procedure to empty the lower portion 
of the colon and this would enable the physician to check 
for anal fissures, bleeding or a tear in the sphincter. 
Patients would be referred to a colon and rectal surgeon 
if any repair was indicated. 

Internists with a subspecialty in gastroenterology 
(whether in a subspecialty practice or part of a general 
internal medicine practice) would most likely have a ded- 
icated room for what is called "flex sig" examinations of 
the lower colon with a flexible sigmoidoscope, a tube with 
fiber-optic light, an eyepiece at one end, and a tiny cam- 
era at the other. The patient is asked to adhere to a liquid 
diet the day before the procedure, then "prepare" the 
colon with a Fleet enema for the procedure, usually 
scheduled the next morning. The patient is not sedated 
and the procedure causes only mild and momentary dis- 
comfort. Therefore, no prep or recovery rooms are 
required; however, a workroom (6x8 feet) opening onto 
the procedure room is ideal (Figure 3-52) to provide suit- 
able accommodation for washing and drying the scopes, 
which are very expensive and delicate and must be han- 
dled with care. A toilet room should open onto the flex sig 
room (Figure 3-52). 

Layout of Procedure Room 

A procedure room 10x12 feet in size is adequate. If space 
is tight, although it's not ideal, the washing and drying of 
scopes can be handled in the procedure room (as in 
Figure 3-72), where flex sig is part of a multiphasic exec- 
utive health screening clinic. In this instance, the scopes 
are soaked in trays containing glutaraldehyde (a powerful 
disinfectant) placed on the countertop. Glutaraldehyde 
has a strong odor that must be exhausted from the room 
(note air grille running horizontally in the sink backsplash) 
to the exterior of the building. With adequate ventilation, 



Internal Medicine 79 




Figure 3-72. Flexible sigmoidoscopy examination room located at 
Center for Executive Health. (Interior architecture and design: Jain 
Malkin Inc.; Photographer: Steve McClelland.) 



there is no detectable chemical odor. The tall cabinet at left 
contains drying racks for the scopes. Details are covered 
in the Endoscopy section. 

The examination table used for a sigmoid procedure is 
usually larger than a standard exam table and is often 
motorized to adjust the height and position of the patient. 
In laying out the exam table and casework in this room, it 
is important to note that the patient lies on his or her left 
side with knees bent with the physician, obviously, work- 
ing from behind the patient. A nurse usually stands at the 



patient's head to help relax the patient and provide reas- 
surance. 

Internal Medicine — Summary 

A large internal medicine suite (5000 to 7000 square feet) 
will have a sigmoidoscopy room, an ECG room with 
treadmill, and a lab with its own waiting area, blood draw, 
and toilet with specimen pass-through. Certain types of 
X-rays may be done in the office and, if so, an X-ray room 
with adjoining darkroom and film viewing area will be 
included in the suite. The business office in a suite of this 
size will be composed of separate rooms for transcription, 
business manager, insurance, medical records, book- 
keeper, and receptionist. A sizable staff lounge should 
also be included. The reader is referred to Chapter 6 for 
guidance in designing suites of this size. 



Endoscopy 

The development of fiber optics has made possible the 
examination of the colon, the lungs (bronchoscopy), and 
the upper gastrointestinal tract with an endoscope. This 
noninvasive instrument has revolutionized surgery, by 
reducing problems from invasive surgery and helping 
doctors detect, and in some cases treat, diseases at an 
early stage. These 4- to 5-foot-long flexible "tubes" have 
powerful fiber-optic lights and allow viewing through an 
eyepiece (fiberscope) or, most often, on a separate video 
monitor (videoscope). Light is transmitted down the tube 
to enable the internist to examine the colon, for example, 
in search of tumors or polyps. The procedure is viewed, in 
real time, on a video monitor placed on a cart or a ceiling- 
mounted arm, visible to both patient and physician during 
the procedure (Figure 3-73). At any point, the physician 
can print a photo to give to the patient or save an image 
to a computer for later use and comparison. 

Endoscopies would generally not be performed in a 
physician's office unless it were a large clinic with a 
specialized suite designed to meet all life safety require- 
ments. A medical office building may have an 
endoscopy center set up as an independent business 



80 Practice of Medicine: Primary Care 




Figure 3-73. Proximal video camera system with standard eyepiece 
coupler for use with flexible fiberoptic endoscopes. (Photo courtesy: 
Welch Allyrf 9 , Skaneates Falls, NY.) 



for the convenience of gastroenterologists in the build- 
ing. It would most likely be owned by gastroenterolo- 
gists and, if the center is properly designed and accred- 
ited, any qualified physician could have privileges there. 
Sometimes endoscopies are performed in ambulatory 
surgery centers in special rooms dedicated to this pur- 
pose. 

Endoscopy on the Rise 

In recent years, colon cancer has been given consider- 
able exposure in the news media, greatly increasing the 
volume of procedures both for flex sig (examining the 
lower 6 inches of the colon) and for colonoscopy (exam- 
ining the upper and lower colon with the scope pene- 
trating as far as 6 feet). In 2000, the ongoing debate 
about the efficacy of colonoscopy (an expensive proce- 
dure and one that insurance companies and HMOs 



would rather not pay for) in terms of saving lives tilted in 
favor of the procedure for individuals over 45 years of 
age. In fact, because many precancerous polyps occur 
in the upper colon where they cannot be seen in a flex 
sig procedure, many now view that procedure with skep- 
ticism as it may give a false sense of security. Despite 
this, because it is an inexpensive screening tool, flex 
sigs are often performed as part of a comprehensive 
physical examination for adults. 

As further evidence of this trend, in 2000, CEO David 
Lawrence announced that Kaiser Permanente Health 
Plan would offer colonoscopy to all members over a cer- 
tain age, even though the enormous cost to provide this 
examination would impose short-range economic hard- 
ship and the benefits would not be realized unless the 
member (patient) stayed with Kaiser for many years. 
Kaiser's mission is to form lifelong partnerships with its 
members and, therefore, it is in Kaiser's best interest to 
keep members healthy. The economic benefits of early 
detection and treatment are well known and often offset 
the cost of early screening. 

For all of these reasons, including the aging population 
demographic, the volume of endoscopy procedures will 
increase as will the need to design efficient suites. 

Components of an Endoscopy Suite 

An endoscopy suite would include: 

Procedure room 

Dressing area with lockers for male/female (M/F) staff 

Dressing area with lockers for patients 

Bathrooms (patients and staff) 

Workroom between procedure rooms 

Prep and recovery room 

Physicians' dictation/charting 

Reception/administration/waiting 

Linen storage 



Internal Medicine 81 



ENDOSCOPY SUITE 




Figure 3-74. Layout of endoscopy suite, 
2737 square feet. (Design: Jain Malkin Inc.) 



ENDOSCOPY SUITE 



2737 SF 



The same procedure room can be used by pulmonologists 
to do bronchoscopies and by gastroenterologists to exam- 
ine the upper Gl tract (esophagus, duodenum, and stom- 
ach) and the lower Gl tract (colon). As a point of informa- 
tion, endoscopy procedure rooms are not considered ster- 
ile. However, there is a benefit to having dedicated rooms 
when a high volume of physicians use the facility and a 



high volume of cases exists. Many hospitals, in fact, sepa- 
rate rooms by function in order to do more procedures 
simultaneously and to facilitate scheduling with physicians. 
In a large group practice or a multispecialty ambulato- 
ry clinic, one might find a layout of rooms similar to that 
shown in Figure 3-74. The number of procedure rooms is 
related to the projected volume of cases. Procedure 



82 Practice of Medicine: Primary Care 



rooms must be large enough to accommodate a Stryker 
cart or gurney, the endoscopy cart with video monitor, 
considerable storage for clean linen and supplies, and a 
resuscitation cart (Figure 3-75). Hampers for soiled linen 
and a clock with second hand are also required. The floor 
should be sheet vinyl with a self-coved base. The door to 
the room must be wide enough to accommodate gurney 
traffic. Rooms need central oxygen and suction, ideally 
coming from the ceiling. There are typically two monitors 
on the endo cart, one is video for the procedure and the 
other for patient information. The patient is given con- 
scious sedation through a vein in his or her arm or hand. 



The patient may intermittently wake up and watch the 
procedure, then doze off, but there is no memory of pain 
or discomfort afterward. 

Procedure Room Lighting. Room lighting is darkened 
during this procedure. Indirect perimeter lighting, which 
could be dimmed, combined with standard 2X4 fluores- 
cents overhead, when more light is required, would be 
ideal. 

Fluoroscopic Examinations. Fluoroscopy may be used in 
a large procedure room with a C-arm X-ray to explore bile 




Figure 3-75. Endoscopy procedure room. 
{Photographer: Jain Mai kin.) 



Internal Medicine 83 




Figure 3-76. Endoscopy recovery area provides maximum privacy for patients and gives nurses maximum visibility. Saint Francis Hospital, Hartford, CT. 
{Interior architecture and design: TRO/The Ritchie Organization, Newton, MA; Photographer: Hedrich Blessing.) 



84 Practice of Medicine: Primary Care 



ducts and the pancreas during an upper Gl exam. These 
organs are accessed through the duodenum with tools that 
feed through the scope tube into those small ducts where 
the camera on the end of the scope won't fit. Contrast 
media are injected into the organ. This is called ERCP 
(endoscopic retrograde colangio-pancreatography). 

Flow 

Patients are typically prepped and recovered in the same 
area. Figure 3-76 shows an attractively designed hospi- 
tal-based prep/recovery area with private rooms, while 
Figure 3-77 shows a prep/recovery area in a medical 
office building endoscopy center. Patients often remove 
their clothes and change into a gown with the cubicle cur- 
tain closed, and their clothes are stored in a basket under 
the gurney, which follows the patient into the procedure 
room which negating the need for dressing rooms. The 
gurney is usually used as the procedure table since it can 
be adjusted in height and saves time in not having to 
transfer the patient to another table. The nurse sets up a 
monitor in the prep area for blood pressure and pulse 
oximetry and this monitor follows the patient into the pro- 
cedure room. A monitor that attaches to the gurney is 
best so that two people (one for the gurney and one for 
the monitor stand) do not have to transport the patient 
into the procedure room and back again. 

The patient is continually monitored during the proce- 
dure and given oxygen, as needed. The recovery period 
is generally 30 minutes during which time patients are 
monitored and observed by a nurse. Physicians will often 
dictate between patients or after several are seen in a 
morning. These procedures are usually performed in the 
morning for the convenience of patients who are required 
to fast and not drink water. 

Workroom for Cleaning Scopes 

This is one of the most important rooms in the suite. All 
equipment is cleaned and readied for use in this room. 
Supplies are stored here, as are the cleaned scopes, 
which are typically hung in a long cabinet with glass doors 
(Figure 3-78). Scopes are very expensive and are han- 
dled with great care. 




Figure 3-77. Endoscopy prep and recovery area. {Photographer: Jain Malkin.) 



Some technicians prefer a separate sink for cleaning 
scopes used In upper Gl and bronchoscopy procedures. 
In any case, a workroom requires at least two sinks set 
into countertops at right angles to each other or parallel. 
The sinks need to be deep and should be lower than the 
standard 34-inch-high countertop. For most people, a 30- 
inch height is fine. As the scopes are long and require 
quite a bit of handling to properly clean, the lowered sink 
is more comfortable. 

The nurse or tech spends a few minutes precleaning 
and leak-testing the scope after each procedure, then 
manually reprocessing or putting the scope in an AER 
(automated endoscope reprocessor). The nurse also 
preps each patient. Therefore, it is unlikely the same 



Internal Medicine 85 




Figure 3-78. Drying cabinet for endoscopes in endoscopy workroom. 
{Photographer: Jain Malkin.) 



person can also keep an eye on recovering patients 
while reprocessing scopes. Somewhere in the suite, if 
not in the workroom, there need to be deep cabinets for 
storing disposables, room for the scope transport cases 
(these look like hard-shell briefcases), and shelves for 
large binders for storing the forceps used in biopsies. 
Each forceps is specific to each size scope, and these 
are often color-coded by the staff into binders for easy 
retrieval. 

The workroom is a busy area, packed with instruments, 
sterilization equipment, bottles of solutions, racks, and 



more. It can easily become cluttered, and therefore the 
room size should not be underestimated (Figure 3-79). A 
room 8x14 feet is the minimum functional size. 

Infection Control Issues. Endoscopic procedure rooms 
are clean, but not sterile. Gl scopes are cleaned with liq- 
uid chemical germicide (LCG) using a very specific pro- 
cedure, which can be facilitated or impeded by the layout 
of the room, the height of the sink, and the locations of air 
and suction. Scopes used for bronchoscopies are usually 
cleaned by sterile technique. With tuberculosis on the 
rise, strict infection-control procedures must be followed. 
Proper reprocessing of endoscopes cannot and should 
not be underestimated as it enhances and contributes to 
patient safety. Attention to reprocessing equipment, pro- 
cedures, and facility design can have enormous econom- 
ic benefits or drawbacks. 

Cleaning Process — Overview. Scopes must be 
reprocessed with a protocol developed by the scope man- 
ufacturer, LCG manufacturer, AER manufacturer, appro- 
priate professional organizations such as SGNA (Society 
of Gastroenterology Nurses and Associates, Inc.) and 
AORN (Association of perioperative Registered Nurses), 
and all appropriate regulatory bodies. Scopes are always 
precleaned by drawing water and detergent into them, 
soaking, washing, scrubbing, and inserting a cleaning 
brush through the channels as part of the process. They 
are leak-tested in the sink. At this point, they can be high- 
level disinfected by manually soaking in trays containing 
glutaraldehyde or in an automated endoscope reproces- 
sor. In the manual process, scopes are rinsed off after 
soaking, then taken to the "clean side" to blow out with 
compressed air, and hung in a cabinet to dry. 

Liquid chemical germicides recently introduced into 
the market have reduced soak times in the AER to as 
low as 5 minutes (from previous lows of 20 minutes). Ten 
air exchanges per hour or a filter device to limit vapor 
exposure are usually recommended when using glu- 
taraldehyde and other LCGs. Although neutralization is 
seldom required, the LCG can usually be neutralized in 
a 5-gallon carboy and then dumped down the drain (a 



86 Practice of Medicine: Primary Care 



# 



V 



V 



U'-O" 

TO PROCEDURE 
ROOM #1 



AIR & SUCTION 




COUNTERTOP 



CLEAN SIDE 




GLUTARALDEHYDE PANS 
OR LOCATION COUNTERTOP 
AUTO REPROCESSOR. 



PLOOR MODEL 
AUTO REPROCESSOR 



COUNTERTOP 



TO PROCEDURE 
ROOM #2 





ENDOSCOPY WORKROOM 



Figure 3-79. Layout of endoscopy workroom. (Design: Jain Malkin Inc.) 



Internal Medicine 87 




Figure 3-80. Countertop model endoscopy automatic 
reprocessor unit. (Photo courtesy: Medivators Inc., 
Eagan, MN.) 



Figure 3-81. Floor model endoscope automatic reproces- 
sor unit. (Photo courtesy: Medivators Inc., Eagan, MN) 



floor drain facilitates the process). AERs include deter- 
gent, disinfectant, filtered water, air, and alcohol treat- 
ment cycles. They are designed to minimize chemical 
vapors and exposure and ensure a uniformly 
reprocessed instrument. Each AER usually requires a !4- 
inch water line with an accessible shutoff valve capable 
of providing 2 to 4 gallons of flow per minute, potable 
cold or hot water, a floor drain, and typically 120 volts ac 
(alternating current) with a 20-ampere line (fused and 
dedicated circuit). Suction and air connections are not 
required. The machines have internal air compressors 
that inject air through the endoscope channels. The 
countertop model in Figure 3-80 is designed for facilities 
that process more than 100 procedures per month, 
whereas the dual-basin floor model in Figure 3-81 is 
intended for higher volume. 



Biopsy forceps and endotherapy devices introduced 
down the scope channels are of the one-time disposable 
or reusable type. The reprocessing protocol involves 
immersion in detergent, ultrasonic cleaning, rinsing, lubri- 
cation, followed by steam sterilization in an autoclave. 

Glutaraldehyde Ventilation Strategies. Glutaraldehyde 
is used for cold sterilization and high-level disinfection of 
medical instruments. Although not proven to be a car- 
cinogenic agent, it is an irritant that can be absorbed by 
inhalation, by ingestion, and through the skin. It has a 
strong odor and requires specific ventilation measures, 
including*: 

• 10 air exchanges per hour 

• A room large enough to ensure adequate dilution of 
vapors 

• Exhaust vents located at the source of the vapor dis- 
charge (Figure 3-71 — note exhaust grille at rear of 
sink) 

• Additional exhaust vents at floor level (glutaraldehyde 
vapors are heavier than air and this pulls the vapors 
down away from the breathing zone) 

• Fresh air supply at ceiling across (opposite) from 
exhaust vents 

• Consideration of outside air intakes, windows, or other 
openings to prevent re-entry of discharged vapor or 
exposure to other occupancies — this air must not be 
recirculated 

• Employing scope cleaning procedures and taking air 
samples to monitor vapor levels at completion of con- 
struction 

Layout of Workroom. The room should have a dirty side 
and a clean side, with the dirty side being larger. 



*The above recommendations are from The Safe and Effective Handling of 
Glutaraldehyde Solutions, SGNA Monograph Series, ©1996 Society of 
Gastroenterology Nurses and Associates, Inc., Chicago. 



88 Practice of Medicine: Primary Care 



Dirty Side. The deep, large sink at 30-inch height would 
have a countertop space on the right and left. The dirty 
scope would be laid down on the left, held in the sink to 
be manually washed with brushes, then placed in the 
automatic disinfector reprocessor or soaked in trays to 
the right of the sink. Suction should be placed on the right 
side of the sink. The autoclave can be placed on the clean 
or dirty side. After the scopes are disinfected, they are 
rinsed off, then carried to the clean side to blow out with 
air and hung to dry. Even with the automatic reprocessor, 
scopes need to be hung in a drying cabinet. Locate a rack 
for gloves near the sink. 

Clean Side. The sink should be on the right side with 
most of the countertop on the left. The sink here should 
also be lowered. Alcohol is used in the final stage of 
reprocessing. It is induced into the channels of the scope 
by syringe to dry any remaining water. Then the channels 
must be purged by air. Compressed air is needed on the 
right side of the sink. (The air compressor fits under the 
sink.) Bacteria grow quickly in damp, dark places. 
Therefore, air is used to blow dry all of the channels, and 
scopes must be hung in a tall cabinet so that they can be 
fully extended whether manual or automatic reprocessing 
(Figure 3-77). Locate a rack for gloves near the sink. A 6- 
inch-deep shelf over the sink is very useful on both the 
dirty and clean sides. 

Miscellaneous Considerations. City water needs to be 
filtered; it's too contaminated. With the automatic 
reprocessor machines, leave space for an external pre- 
filtration system. Foot-pedal control for water at both sinks 
is ideal, but it must be a high-quality unit that has good 
temperature control and provides adequate flow. 

Storage. Provide adequate storage in the workroom for 
boxes of gloves, masks, and disposable gowns, which 
provide a better barrier than linen. Storage for many gal- 
lon bottles of solutions must be accommodated. 

Regulatory Agencies. Endoscopy facilities are state 
licensed, they require Medicare certification, and it is 



anticipated that they will soon have to be accredited by 
JCAHO or AAAHC (see Chapter 15) in order to get man- 
aged care contracts. 

Recovery Room 

The recovery room is standard in all respects, with oxy- 
gen and suction at each bed and privacy curtains sepa- 
rating each patient. Recovery time is normally half an 
hour, and recovering patients should be in view of nurs- 
ing staff (Figures 3-73 and 3-75). 



Interior Design 

The interior design of an internal medicine suite should be 
tailored to the functional needs of the patient population. If 
the internist is a cardiologist or a pulmonologist, for exam- 
ple, those patients may, for the most part, be elderly. 
Therefore, a conservative color palette and furnishings 
might be appropriate. An oncologist, on the other hand, 
would have a broad age range of patients and a more 
upbeat design might be in order. A more important consid- 
eration is the socioeconomic level of the patients served to 
tune the design to their expectations and comfort. Color 
Plate 4, Figure 3-82, is a cardiac surgeon's waiting room. 
Patients visit the office preoperatively and postoperatively, 
on two or three afternoons a week. The remainder of the 
time, the office is a home away from home for the surgeon 
— a place to relax, sleep, prepare slides for lectures, and 
meet with colleagues to discuss cases. 



PEDIATRICS 

A pediatrician treats children from birth through adoles- 
cence (age 18). The office visits are frequent and of rela- 
tively short duration in the exam room, but frequently involve 
a protracted period of time in the waiting room. This is a high- 
volume specialty, and the practice is almost always com- 
posed of two or more physicians. It is rare to find more than 
three pediatricians working in the same office, although a 
busy practice may staff a second or third office. 



Pediatrics 89 



Waiting Room 

Waiting rooms must be larger than for other specialties, 
as parents often bring all their children and sometimes a 
grandparent, when one child has to visit the doctor. 
Pediatric offices often have a sick-baby, or contagious, 
waiting room and a well-baby waiting room (Figure 3-83). 
The reason for this is to limit contagion. Since physicians 
do not make house calls, children with infectious dis- 
eases are brought into the office, where well children who 
are waiting for a routine checkup or an injection are vul- 
nerable to contracting them. 

If space is limited, a sick-baby waiting room can be 
devised by direct entry into an exam room (Figure 3-84). 



*P|&D\4TKl£/S 



Table 3-3. 
Analysis of Program. 

Pediatrics 




No. of Physicians: 




2 




3 


Business Office 




12X16=192 




14X18=252 


Exam Rooms 3 


6@ 


8X10=480 


9@ 


8X10=720 


Adolescent Exam 




8X12=96 




8X12=96 


Minor Surgery 




— 




12X12=144 


Toilets 


2@ 


7X8=112 


2@ 


7X8=112 


Consultation Room 


2@ 


10X12=240 


3@ 


10X12=360 


Nurse Station 




10X12=120 




12X12=144 


Staff Lounge 




10X12=120 




10X12=120 


Waiting Room/Sick Baby 


1 


2X14=168 




12X14=168 


Well Baby 




18X20=360 




22X26=572 


Storage 




6X8=48 




6X8=48 


Subtotal 




1936 ft 2 




2736 ft 2 


20% Circulation 




387 




547 


Total 




2323 ft 2 




3283 ft 2 



Figure 3-83. Schematic diagram of pediatrics suite. 



"Designer may wish to make one exam room 1 0x1 2 feet for use as a minor surgery 
room, as well as provide a staff lounge, if space permits. 



One exam room would have a door to the outside or 
building corridor, as the case may be, and would have a 
buzzer or bell to summon the nurse for entry. The nurse 
would tell the mother, over the phone, to come to that 
door and buzz. The door would be marked Contagious 
Entrance. The sick-baby exam should be near a toilet, 
and the room must have a sink. 

If the suite is large enough to have a contagious wait- 
ing room, one exam room in close proximity to the wait- 
ing room should be designed as a sick-baby exam room, 
with a sink cabinet and a toilet nearby. The other exam 
rooms should be clustered around the nurse station 
(Figure 3-85). 

In this specialty, it is a good idea to have a toilet acces- 
sible from the waiting room so that parents may change 
diapers in advance of entering the exam room, and the 



90 Practice of Medicine: Primary Care 



68-0" 




PEDIATRICS 



2992 SF 
Figure 3-84. Space plan for pediatrics, 2992 square feet. (Design: Jain Malkin Inc.) 



Pediatrics 91 




PEDIATRICS 



2400 SF 
Figure 3-85. Space plan for pediatrics, 2400 square feet. {Design: Jain Malkin Inc.) 



92 Practice of Medicine: Primary Care 





Figure 3-86. Fold-down baby changing station. (Photo courtesy: Koala Corporation, Denver, 
CO.) 



Figure 3-87. Toddler seat. {Photo courtesy: Koala Corporation, Denver, CO.) 



staff is not continually interrupted in order to direct chil- 
dren to the bathroom (Figures 3-83 and 3-84). The bath- 
room should have a sink countertop large enough to 
change diapers on, a shelf for disposable diapers, talcum 
and paper towels, and a large trash receptacle. An ameni- 
ty is a wall-mounted, drop-down baby changing station 
(Figure 3-86). A wall-mounted seat keeps toddlers secure 
while a parent uses the restroom (Figure 3-87). A com- 
pactor for dirty diapers, purchased at a baby store, would 
be useful. 



Doctors disagree on the practicality of having a child's- 
height drinking fountain in the waiting room. If the room is 
not well supervised, it can lead to mayhem. 

The waiting room should contain some tables or flat 
areas built into the seating where parents can put down 
an infant in a carrier without occupying an adult's seat 
(Figure 3-88). A pediatric waiting room may be as large 
as space and budget permit. Each patient is accompa- 
nied by one to three people. Children can get pretty rowdy 
playing in a pediatrician's waiting room, so an effort 



Pediatrics 93 





Figure 3-88. Pediatric waiting room. Note magnetized tic-tac-toe board at rear of playpit. (Design: Jain Malkin 
Inc.; Photographer: John Waggaman.) 



Figure 3-89. Children's playpit. (Design: Jain Malkin Inc.; 
Photographer: Michael Denny.) 



should be made to occupy them with something unique. 
A carpeted playpit (Figure 3-89) or seating unit (Figure 
3-88) can be designed. 

Built of plywood, then padded and upholstered with car- 
pet, these custom-built units appeal to children's need for 
physical movement. Their pent-up energy can be released 
while "driving" a fire truck (Figure 3-90) or riding "Nessie" 
(Figure 3-91 ). In fact, a waiting room that is designed imag- 
inatively can be so appealing to children that it results in 
tantrums when it is time to leave. Custom play furniture 



must be designed to eliminate sharp corners and edges 
against which a toddler may fall and become injured. 

The waiting room should also contain bins for toys and 
racks for magazines, at a height accessible to children. 
Pediatricians disagree in their choice of toys for this room. 
More conservative physicians tend to feel that toys 
spread infection (drooling on toys, fingers in mouth, etc.) 
and will limit the type of amusements they condone. 
Younger pediatricians seem to be more relaxed and icon- 
oclastic (many refuse to wear white coats, which may 



94 Practice of Medicine: Primary Care 




Figure 3-90. Play fire engine. {Photo 
courtesy: People Friendly Places, Inc., 
Northbrook, IL.) 



Figure 3-91. Sea monster. (Photo cour- 
tesy: People Friendly Places, Inc., 
Northbrook, IL.) 





Figure 3-92. Clown puzzle wallgraphic. [Design: Jain Malkin Inc.; Photographer: 
Michael Denny.) 



frighten children) and feel that germs are everywhere 
and inevitable. If a child is not exposed to germs in the 
office, he or she will surely be exposed to infection from 
playmates. 

In a pediatric waiting room, one may break the rule 
about providing individual chairs. One may take liberties 
in furnishings here, since it is a homogeneous population 
— mostly parents from the same neighborhood, approxi- 
mately the same age, and sharing a common interest — 



their children. Thus, parents do not seem to mind sitting 
next to each other in continuous (common seat and back) 
seating. Figures 3-84, 3-87, and 3-92 show this type of 
seating, which saves space and accommodates a maxi- 
mum number of people in a small waiting room. Whatever 
the type of seating provided, one may wish to provide a 
few standard-height chairs, with arms, for pregnant 
women, who often find it difficult to get out of low, lounge- 
type seating. 



Pediatrics 95 




Figure 3-93. Pediatric waiting room, com- 
munity clinic, features saltwater aquarium 
with built-in bench, recessed niche for TV, 
and upholstered corral for toddlers. 
(Interior design: Jain Malkin Inc.; 
Photographer: Steve McClelland.) 



Other design ideas for the waiting area include a 
large built-in saltwater aquarium and an upholstered 
"corral" to keep toddlers safely in view (Figure 3-93). A 
clever wall-mounted unit by People Friendly Places, Inc., 
keeps toddlers engaged (Figure 3-12), while a puppet 
theater appeals to older kids (Figure 3-94). Colorful wall 
murals based on children's art would be appropriate for 
a young patient population (Figure 3-95). A colorful 
design using geometric patterns would appeal to a larg- 
er age range (Color Plate 5, Figure 3-96). A unique des- 



tination treatment, with celestial theme, cues wayfinding 
(Color Plate 6, Figure 3-97). There is no end to the fan- 
ciful design ideas that can be implemented in a pediatric 
office. In the Victor Yacktman outpatient pediatric facility, 
Color Plate 6, Figures 3-97 and 3-98, public areas fea- 
ture photos of physicians wearing funny hats and mak- 
ing funny faces. The reader is referred to Chapter 12 for 
additional information on furnishings and interior finish 
specifications. Note Figures 12-16, 12-17, and 12-18. 



96 Practice of Medicine: Primary Care 




Figure 3-94. Puppet theater in waiting room keeps children occupied. 
{Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Figure 3-95. Children's art makes wonderful wallgraphics. {Design: Jain 
Malkin Inc.; Photographer: John Waggaman.) 



Pediatrics 97 



Examination Rooms 

Number of Exam Rooms. Each pediatrician should have 
a minimum of three exam rooms, but four is better. It is 
important to plan for growth. A pediatric practice grows 
rapidly, and before long, a two-physician practice with five 
or six exam rooms will be able to use eight. Thus, the 
designer should guide the client at the outset to lease a 
large enough space. Since examinations are short, the 
physician can quickly move on to the next patient while the 
mother is dressing the child and the nurse cleaning up the 
last exam room. 

It is a good idea to make one exam room large enough 
to accommodate an infant exam table and a child's table, 
since it is more efficient to examine two siblings in the 
same room (Figure 3-84). 

Adolescent Patients. Most pediatric practices (particular- 
ly true with older physicians who have been in practice a 
number of years) must accommodate a number of adoles- 
cent patients. A standard-sized adult exam room (8X12 
feet) should be provided, with a standard-sized pelvic exam 
table and decor suitable to a teenager. Care must be taken 
in the interior design of the office not to gear it too much to 
infants and toddlers, as it may offend the older patients who 
are quite sensitive about being considered children. Rooms 
designed to accommodate older children should have a 
floor scale. Since children may be shy or modest about 
being weighed at the nurse station, it is best to have a scale 
in the exam room (Color Plate 6, Figure 3-97). The family- 
centered exam room in Figure 3-97 is part of a large out- 
patient pediatric clinic associated with a hospital. 

Location of Sinks. Some physicians consider it unnec- 
essary to have a sink in every exam room if a sink is avail- 
able nearby in the corridor. However, it is more efficient to 
have a sink in each exam room, since children may vomit 
or urinate during an examination and having a sink in the 
room saves time, by eliminating the need to leave the 
room in order to clean it up or wash hands. Today, with 
extreme concern about infection control, a sink in the 
exam room seems mandatory. 




Figure 3-100. Pediatric exam room. Child climbs stairs at foot end of fire 
truck to reach the tabletop. Exam table by Good Time Medical, Chicago, 
IL. (Interior design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Size of Rooms. Pediatric exam rooms may be quite small, 
particularly an infant room. They need not have a door that 
opens to shield the patient. In fact, frequently exam rooms 
are so small that a pocket door is the most practical solu- 
tion. An infant room may be no more than 6x8 feet (see 
Figure 3-83). For a standard (noninfant) pedo exam room, 
8x10 feet is a good size. A guest chair for the parent 



98 Practice of Medicine: Primary Care 



should be included and, if space permits, a small writing 
desk for the doctor (Color Plate 5, Figure 3-99). The rooms 
in these space plans may seem small, but pediatricians 
often prefer to make the exam rooms minimum size in 
order to squeeze in an "extra" exam room. 

Exam Tables. Pediatric exam tables are available as 
manufactured items (Figures 3-100 and 3-101), but may 
be custom-built with storage underneath (Figure 3-102). 
The table must also have a paper roll holder inside the 
cabinet with a slot in the table top so that a continuous roll 
of paper can be pulled over the vinyl-covered exam table 
pad and quickly changed between patients. 

The size is 2x4 feet for an infant table (this increases 
to 6 feet if a lowered portion for a baby scale is included) 
or 2x6 feet for a child's table. The table is always placed 
against a wall to minimize the hazard of a child falling off. 
It should be positioned so that the doctor can examine 
from the right side of the patient, unless the doctor is left- 
handed and examines with the left hand. If a lowered area 
for a baby scale is not incorporated into the table, a por- 
tion of the sink cabinet countertop should be lowered for 
this purpose. It is better, however, to reserve this lowered 
portion of the sink cabinet for a doctor's writing desk. The 
infant exam table in Figure 3-103 has a digital scale and 
digital infantometer to measure infant length (with option- 
al electrical or battery operation). 





Figure 3-102. Infant exam room with custom-built exam table 
with lowered section to accommodate infant scale. (Design: 
Jain Malkin Inc.; Photographer: Michael Denny.) 



Figure 3-103. Infant exam table with built-in digi- 
tal scale and measuring device. (Photo courtesy: 
Hausmann Industries, Inc., Northvale, NJ.) 



Figure 3-1 01 . Pediatric exam table with built-in 



measuring device and space for infant scale. 
(Photo courtesy: Good Time Medical, Chicago, IL.) 



Pediatrics 99 




PEDIATRICS (PLAN DONE PRIOR TO ADA) 

4500 SF 
Figure 3-104. Space plan for pediatrics, 4500 square feet. {Design: Jain Malkin Inc.) 

100 Practice of Medicine: Primary Care 




PEDIATRIC EXAM ROOM 



Figure 3-105. Pediatric examination table, with wrap-around bench for 
parent, and sink cabinet. (Design: Jain Malkin Inc.) 



It is possible to design an exam table that wraps 
around the corner to incorporate a bench for the parent, 
a scale space, and a sink cabinet (see Figures 3-104, 
3-105, and 3-106). It should be noted that any storage 
that is accessible to children in an exam room should be 
locked. Otherwise, they will empty the cabinets regularly 
or catch their fingers in the doors or drawers. 

Some method by which one may measure an infant's 
length may be incorporated into the exam table (Figure 
3-100). The length of the table on one side can be routed 




PEDIATRICS 



2915 SF 



Figure 3-106. Space plan for pediatrics, 2915 square feet. (Design: Jain Malkin Inc.) 



Pediatrics 101 




Figure 3-107. Nurse station, pediatric community clinic. Note infant exam table with scale and 
measuring device. Blood draw chair fits in niche. {Interior design: Jain Malkin Inc.; 
Photographer: Steve McClelland.) 



with a slot for a yardstick, and a sliding wooden arm may 
be pushed up to the baby's feet to hold the child steady 
and, at the same time, indicate on the tape the child's 
length. A table that weighs and measures infants is some- 
times located in the nurse station (Figure 3-107). 

Interior Design. Exam rooms should be gaily decorated 
with one or two walls of colorful patterned wallcovering or 
a wallcovering border placed at a height where children 
can note it, perhaps a patterned tile floor and ceiling tiles 
(Color Plate X, Figure 3-98), and artwork of interest to chil- 
dren. Pediatric exam rooms should never be carpeted. 
Sheet vinyl or vinyl composition tile are recommended. 
Wallcovering even catches the attention of infants and 
serves to distract them, thus making the doctor's exami- 
nation that much easier. One of the papered walls should 
be the long wall behind the exam table so that babies can 
see it while lying down. Art images that are pictorial with 
a lot of detail (items to identify, count, or name the color) 
can be used by nurses to gauge the developmental sta- 
tus of a young child. 



Nurse Station 

Pediatric suites require large nurse stations because the 
nurses administer many injections. After an injection, a 
patient must be observed for 15 to 20 minutes in order to 
note any negative reaction to the drug. A few chairs or a 
bench must be provided either in the corridor adjacent to 
the nurse station or perhaps within the nurse station 
(Figure 3-105). The nurse can attend to other business, 
but still keep a watchful eye on the patient. A full-size 
refrigerator must be accommodated in the nurse station. 
Pediatricians who administer allergy shots should have a 
nurse station located near the front of the suite, so that 
patients coming just for injections can enter and leave 
without adding to the congestion in the examination area 
of the suite. The nurse station should have a knee space 
area with telephone, space for a microscope, and a dou- 
ble sink. 



102 Practice of Medicine: Primary Care 



Business Office 

The business office is as described under Family 
Practice, although sometimes the nurse station can be 
combined with the business office (Figure 3-84). This is 
efficient in a small office, as the staff can cover for one 
another during critical periods of the day. 

The pediatric business office should have a reception 
window facing both the sick and the well waiting rooms 
(see Figure 3-84). The appointment/cashier counter 
needs to have a wide shelf or a secure niche in the wall 
where a parent may put an infant in a carrier while he or 
she is writing a check or chatting with the staff (Figures 
3-83 and 3-84). 

The reception window should be designed in such a 
manner as to appear "friendly" and nonclinical. That 
shown in Color Plate 7, Figure 3-108, incorporates 
French windows, ivory painted trim, and a fanciful carpet 
inset — all very residential in character. The reception 
window in Figure 3-109 and the adjacent wallgraphic are 
bright and playful, executed in primary colors. 

A busy practice, with perhaps three physicians seeing 
patients simultaneously, benefits greatly from a separa- 
tion of incoming and outgoing traffic. Figure 3-103 is 
designed for patients to enter through one door and leave 
through another, without exiting through the waiting room. 
This greatly enhances productivity and reduces crowding 
and stress. Note that both the reception and the cashier 
counters are very wide, to accommodate a number of 
transactions simultaneously. The electrical plan and 
reflected ceiling plan for this suite (Figure 3-103) can be 
found in Chapter 13. 



Consultation Room 

Pediatricians spend little time in a consultation room and 
seldom see patients there. Therefore, it is not uncommon 
for two physicians to share a private office (see Figure 
3-105). Basically, it is used for housing medical reference 
books and for returning phone calls. Pediatricians dis- 
pense a lot of literature and pamphlets on child care, so 




Figure 3-109. Fabric canopy makes a reception desk festive. (Design: Jain Malkin Inc.; 
Photographer: Jain Malkin.) 



Pediatrics 103 



a wall rack should be provided for the organized storage 
of these materials, either at the nurse station or in the cor- 
ridor adjacent to exam rooms. 



Corridor 

One corridor should be selected for a 20-foot refraction 
lane. An eye chart would be tacked to a door or placed 
on the wall at the end of the corridor for a brief eye 
test. A circle inset into the carpet can mark where the 
child's heels should be placed to assure a distance of 20 
feet. An alternative to this is an automated refractor that 
sits on a 2-x4-foot table with the patient on one side 
and the aide or tech on the other or a handheld auto- 
mated refractor which is even quicker (Figure 4-80). 
Corridors should be cheerful and may have cartoon 
characters or colorful graphics (Figure 3-95 and Color 
Plate 5, Figure 3-96). 



Hearing Test Room 

Some pediatricians like to do a preliminary hearing test to 
screen patients who need to be referred to an ENT spe- 



cialist. Sometimes this can be set up in a dual-purpose 
room. The hearing test can be performed in a multipur- 
pose consulting room or in a small 8-x8-foot room dedi- 
cated to that purpose. One needs a table 24X48 inches 
on which to place the equipment (Figure 4-143), a chair 
for the patient, and one for the technician. Walls of the 
room must have sound insulation and, inside the room, 
walls may be covered with carpet to provide further sound 
attenuation. The room should be located at the rear of the 
suite away from the hectic front office (see Figure 3-104). 



Storage 

The office needs a small storage room, 6x8 feet, for drug 
samples, disposable supplies, office forms and stationery, 
and handout pamphlets. 



Interior Design 

The suite should be colorful and imaginatively designed to 
reduce the children's anxiety and make them forget any 
negative associations they may have had about visiting the 
doctor. All rooms except exam rooms may be carpeted. 



104 Practice of Medicine: Primary Care 



CHAPTER 4 

Medicine: 
Specialized Suites 



The American Board of Medical Specialties recognizes, as 
of this writing, 25 medical specialties and about a dozen and 
a half subspecialties. The specialties are Allergy and 
Immunology, Anesthesiology, Colon and Rectal Surgery, 
Dermatology, Family Practice, Internal Medicine, 
Neurological Surgery, Nuclear Medicine, Obstetrics and 
Gynecology, Ophthalmol-ogy, Orthopedic Surgery, 
Otolaryngology, Pathology, Pedi-atrics, Physical Medicine 
and Rehabilitation, Plastic Surgery, Preventive Medicine, 
Psychiatry, Neurology, Radiology, General Surgery, 
Thoracic Surgery, Urology, Emergency Medicine, and 
Medical Genetics. 

Subspecialties under Internal Medicine are Cardiovas- 
cular Disease, Endocrinology, Diabetes and Metabolism, 
Gastro-enterology, Hematology, Infectious Disease, 
Medical Oncol-ogy, Nephrology, Pulmonary Disease, 
Rheumatology, Adolescent Medicine, Clinical Cardiac 
Electrophysiology, Critical Care Medicine, Clinical and 
Laboratory Immunology, Geriatric Medicine, and Sports 
Medicine. Subspecialties under Pediatrics are Pediatric 
Cardiology, Pediatric Gastro-enterology, Pediatric 
Endocrinology, Pediatric Hematology-Oncology, Neonatal- 
Perinatal Medicine, Nephrology, Pediatric Critical Care 
Medicine, Pediatric Emergency Medicine, Pediatric 
Infectious Diseases, Pediatric Rheumatology, Sports 
Medicine, Medical Toxicology, Adolescent Medicine, and 
Clinical Laboratory Immunology. There are a few other sub- 
specialties under Psychiatry and Neurology, such as Child 
and Adolescent Psychiatry and Child Neurology. 



Although Family Practice, Pediatrics, and Internal 
Medicine are primary medical practices, they are also listed 
as specialties by the American Board of Medical 
Specialties, since physicians in these specialties must take 
and pass specialty boards that certify their competence in 
their respective fields. These three "specialties," then, are 
primary-practice physicians, whereas many of the other 
specialties listed above tend to be referral specialties — 
patients are referred by their primary-care physicians. 

This chapter will discuss the requirements of the medical 
specialties the designer or architect is most likely to 
encounter in a medical office building. It is assumed that the 
reader will have read Chapter 3, which is the foundation for 
Chapter 4. 

As a general comment, the same economic pressures 
and regulatory issues that have affected primary-care 
physicians have impacted specialty care. When the second 
edition of this book was published in 1990, physicians 
wanted to do as many tests as possible in their offices to 
capture the additional revenue. Today, in many parts of the 
United States, reimbursement is so low that the more pro- 
cedures one does, the more one loses. Medicare is the 
largest payer in the United States, and what it will or will not 
cover and the amount it pays influences other payers as 
well as the types of procedures physicians are willing to do 
in their offices. If it's not reimbursed, the patient may be 
referred to the local hospital for the procedure. 

In writing the new edition of this book, the author sent sec- 
tions of the text to several physicians in each specialty asking 



105 



them to review it for accuracy. It was surprising to note the 
following commonalities in their responses: 

• More space for administration for increased paperwork 
associated with managed care. 

• No great interest in upgrading to digital diagnostic 
instrumentation due to cost and retraining unless 
forced to buy new equipment. 

• When electronic medical records become prevalent, it 
may be practical to provide an area in the waiting room 
for patients to update their charts or medical histories 
(Figure 4-137). 

• A computer at all staff workstations and centrally locat- 
ed at nurse stations. This makes it easy to retrieve lab 
results. 

• Anticipated increase in regulation (codes, accredita- 
tion, and licensing) of office-based surgery, specifical- 
ly affecting dermatologists, plastic surgeons, otolaryn- 
gologists, and oral surgeons. 

• Increased emphasis on patient privacy as a response 
to HIPAA (see the Introduction), JCAHO, and other 
regulatory or accreditation agencies. 



SURGICAL SPECIALTIES 

To avoid redundancy, certain issues common to all surgi- 
cal specialties with respect to minor surgery rooms and 
office-based outpatient surgery suites will be discussed 
here, rather than under each specialty heading. However, 
the Plastic Surgery section has the most complete dis- 
cussion of office-based surgery suites in terms of layout 
and design issues. 

Physicians with specialties in OB-GYN, otolaryngology 
(ENT), ophthalmology, dermatology, plastic surgery, gen- 
eral surgery, urology, and, occasionally, orthopedic sur- 
gery, will have a minor surgery or special procedures 
room where they may use local anesthetics, which 
requires no special accommodation. 



Conscious Sedation/Minor Procedures 

The next step up is conscious sedation, which involves 
intravenous (IV) sedatives like Valium®, often combined 
with an agent that acts like an amnesiac so that the mem- 
ory of pain is erased. When conscious sedation is admin- 
istered, monitoring equipment and a resuscitation cart are 
required. Urologists often use this type of sedation when 
performing cystoscopies, but many physicians are reluc- 
tant to assume the liability and risks of using conscious 
sedation in their offices unless they do many procedures 
that require it and have properly trained staff to monitor 
patients. As an option, a surgeon may contract with an 
anesthesia service to assist in a procedure. An anesthesi- 
ologist or nurse anesthetist with a portable anesthesia 
machine will come to the surgeon's office as scheduled. 



Office-Based Surgery 

Plastic surgeons are the most likely physicians to have an 
office-based surgery center within their suite, followed by 
dermatologists and, occasionally, otolaryngologists. As 
statutes and codes vary widely from state to state, the fol- 
lowing comments reflect national trends driven by 
Medicare for facility certification or AAAHC accreditation. 
See also Chapters 7 and 15 for more in-depth discussion 
of regulations and codes. 

As a prelude, it should be noted that physicians setting 
up office-based surgery suites have historically had con- 
siderable flexibility in the layout of these facilities, gener- 
ally trying to fit two pounds of program into a one-pound 
container. Operating room sizes, space around each 
recovery bed, and ancillary rooms (clean and soiled utili- 
ties, scrub area, staff and patient dressing areas) have 
been left largely to the discretion of the physician, some- 
times resulting in "funky" layouts. It is common to find a 
"prep room" in which clean and soiled are accommodat- 
ed side by side, rather than in separate rooms. Minimum- 
width corridors and clearances may also have been com- 
promised. Unless physicians seek Medicare certification 
in order to be able to bill a fee for the use of the facility (in 



106 Medicine: Specialized Suites 



addition to the surgeon's fees), they often can avert close 
scrutiny on these issues. However, numerous states and 
national accreditation agencies are currently raising the 
bar on office-based surgical facilities to ensure greater 
patient safety and standardization. This will result in larg- 
er surgery suites and greater cost. 

In fact, surgery performed in office-based settings is 
gaining the attention of state legislators and regulators 
throughout the nation. A recent article in AORN Journal 
(April 2001) forecasts that 20 percent of surgical proce- 
dures in 2001 will be performed in physicians' offices. The 
article details the ongoing measures in various states to 
assure patient safety. 

Even JCAHO (Joint Commission on Accreditation of 
Healthcare Organizations) has stepped up to the plate 
with its Office-Based Surgery (OBS) Standards, approved 
2001, intended for physicians and dentists performing 
operative and invasive procedures in an office setting. To 
be eligible for accreditation under the OBS standards, a 
provider must meet all of the following criteria: 

• The practice comprises three or fewer licensed inde- 
pendent practitioners performing surgical procedures. 

• The organization or practice must be physician owned 
or operated such as a professional services corpora- 
tion, private physician practice, or small group practice. 

• Invasive surgical services are provided to patients and 
local anesthesia, minimal sedation, conscious seda- 
tion, or general anesthesia are administered. Practices 
providing procedures such as excisions of skin lesions, 
moles, and warts or draining of abscesses limited to 
the skin and subcutaneous tissue typically do not fall 
under OBS standards. 

• OBS practices that render four or more patients inca- 
pable of self-preservation at the same time are 
required to meet the provisions of the Life Safety Code, 
NFPA 101, of the National Fire Protection Association 
(NFPA). 

Office-based surgery suites often fall into a "gray area" 
in terms of codes. For example, the Uniform Building Code 



(UBC) classifies them as a "B" or office occupancy if fewer 
than five individuals are incapable of self-preservation, 
which limits the enterprise to two ORs and three recovery 
beds or one OR and four recovery beds. (NFPA 101 limits 
it to four persons or fewer.) The local department of public 
health will, in many jurisdictions, send an inspector to 
review life safety issues and this individual may demand 
accommodations that go beyond what is stipulated in the 
local building code and in NFPA 101 Life Safety Code. 

An example might be that the surgery portion of the 
suite be separate from the physician's office practice with 
a dedicated entry and reception office. This seems 
unwarranted in a one-physician practice in which the doc- 
tor can only be in one place or the other. However, from 
the standpoint of patient safety, in theory, nothing would 
preclude the physician from allowing an "outside" physi- 
cian to see patients while he is performing surgery and 
the front office staff might be distracted when called upon 
to assist in an emergency to evacuate a patient. 

Nevertheless, this results in the need for additional 
staff and additional space, which might exceed the physi- 
cian's budget. 

Physicians will want to be accredited by one of a num- 
ber of possible agencies that vary, in terms of physical 
design considerations, from flexible to rigorous. See 
Plastic Surgery for more detail. 

To reflect the range of options the architect or designer 
may encounter, the suite plans in this book demonstrate 
both types of office-based surgery suites — those that 
meet physicians' functional needs but may be somewhat 
idiosyncratic in layout, as well as those meeting more rig- 
orous standards, which is where things are headed. 



OBSTETRICS AND GYNECOLOGY 

This is a high-volume practice, so patient flow must be 
carefully analyzed. Obstetrical patients usually make 
monthly visits, which entail weighing and a brief exami- 
nation. Gynecology patients require a more lengthy pelvic 
examination. This type of practice requires a large staff as 
each physician needs one or two nurses; often, two 



Obstetrics and Gynecology 107 



£E>/<SYH 




Figure 4-1. Schematic diagram of an OB-GYN suite. 

Table 4-1 . 

Analysis of Program. 

Obstetrics and Gynecology 



No. of Physicians: 




1 






2 












(Plus N 


urse Practitioner) 


Exam Rooms 


2@ 


8 X12 


X 192 


7@ 


8 X12 


X672 


Exam/Ultrasound 




10 X10 


X 100 




10 X10 


X100 


Consultation Room 




12 X12 


V 144 


2@ 


12 X12 


X288 


Nurse Station 




8 X10 


X 80 a 


2@ 


8 X12 


X192 


Laboratory 




— 






12 X16 


X192 


Toilets 


2@ 


7X8 


X 112 


4@ 


7X8 


X 224 


Minor Surgery 




12 X12 


X 144 




12 X14 


X168 


Staff Lounge 




10 X12 


X 120 




12 X14 


X168 


Storage 




6X8 


X 48 




10 X12 


X120 


Nurse Practitioner 




— 






10 X10 


X100 


Business Office/Bookkeeping 




12 X16 


X 192 




12 X30 


X 360" 


Medical Records 




— 






10 X14 


X140 


Waiting Room 




12 X20 


X 240 




14 X30 


X420 


Subtotal 






1372 ft 2 






3144 ft 2 


20% Circulation 






274 






629 


Total 






1646 ft 2 






3773 ft 2 


"Combined with lab. 














includes reception, bookkeeping, 


and 


insurance 











physicians share three nurses or aides in addition to the 
front office staff. It is customary for a female nurse to be 
present during pelvic examinations, necessitating more 
staff per doctor than required with many other medical 
specialties. Figure 4-1 shows the relationship of rooms. 



Nurse Practitioner 

A trend in this field is the use of nurse practitioners and 
midwives to perform routine patient examinations. A regis- 
tered nurse (R.N.) with additional training in OB-GYN can 
be certified to work in this capacity (refer to Chapter 3 for 
more detail). This frees physicians from routine pelvic 
examinations and Pap smears on healthy patients, allow- 
ing them to concentrate on diagnosis of disease. Offices 
using nurse practitioners will need larger nurse stations or 
perhaps a small private office for them (Figure 4-2). 



Patient Flow 

There probably would not be more than three doctors 
working in an office at one time even if it were a four- or 
five-person practice, since one or two doctors may be 
delivering babies, making hospital rounds, or taking the 
day off. There should be three to four exam rooms per 
physician. The patient flow is from waiting room to weigh- 
ing area, to toilet (urine specimen), to exam room. A good 
space plan will channel patients to each area by the most 
direct route with no backtracking or unnecessary steps. If 
possible, the nurse station/sterilization/lab areas should 
be located toward the front of the suite (centralized) so 
that the staff can cover for each other, and duplication of 
personnel is avoided. 



Waiting Room 

The waiting room of an OB-GYN suite should be large 
and comfortable. Unexpected deliveries frequently make 
the doctor late and necessitate a long wait for patients. 



108 Medicine: Specialized Suites 



44-0 



Figure 4-2. Space plan for OB-GYN, 4488 square feet. 
The plan was designed for two physicians with a nurse 
practitioner and a part-time physician who does not have 
a consultation room. {Design: Jain Malkin Inc.) 




OB-GYN 



4488 SF 



Obstetrics and Gynecology 109 



102-0" 




CHARTS 



I S I 



D D 



i 



o 



r\J 



iO 



lO 



OB-GYN 



3264 SF 
Figure 4-3. Space plan for OB-GYN, 3264 square feet. {Design: Jain Malkin Inc.) 



The patient is apt to be more forgiving if her wait is in a 
well-designed room with good lighting, current maga- 
zines, comfortable seating, and interesting artwork on the 
walls. A play area for children would be a practical addi- 
tion to the waiting room, since many patients are young 
mothers, who are apt to bring their children with them. 



Exam Rooms 

Exam rooms may have attractive wallcovering, carpet, 
and a dressing area where patients may disrobe in priva- 
cy and hang underwear out of sight. Upon dressing, they 
may check makeup and hair in a mirror before leaving the 
exam room. This dressing area may be a 3-x3-foot cor- 
ner of a room with a ceiling-mounted cubicle drape and a 



chair or built-in bench. Or, it can be a hinged space-saver 
panel that opens perpendicular to the wall. Note that in 
Figure 4-3 the dressing area is spacious and offers total 
privacy. Remember that the door to the exam room must 
open to shield the patient. 

The position of the sink cabinet is particularly important 
in an OB-GYN exam room. The physician should be able 
to examine the patient with the right hand and reach for 
instruments from the cabinet with the left hand (Figure 
4-4). The exam table used here is a pelvic table with stir- 
rups. Such tables often have a built-in speculum warmer. 
Alternatively, one drawer of the sink cabinet may have an 
electrical outlet at the rear for warming instruments. Three 
electrical outlets are required: One must be located near 
the foot of the table for the examination lamp used for 
pelvic exams; one should be located above the sink coun- 



110 Medicine: Specialized Suites 



tertop; and the third would be located on the long wall, 
near the head of the table. 

It should be noted that some OB-GYN physicians pre- 
fer a wider examination room with a cabinet that runs 
along the wall at the foot of the exam table (Figure 4-5). 
This cabinet is at a 30-inch height so that the physician, 
when seated, can comfortably reach instruments and 
equipment. Note that, in this instance, patient education 
is handled in the exam room, with a TV monitor built into 
the cabinet. Monitors are wired to VCR units in the busi- 
ness office. The nurse selects the proper tape for the 
patient's viewing; thus, time spent waiting in an exam 
room can be productive. Figure 4-6 shows the cabinets 
opened. These exam rooms are carpeted, except for a 3- 
foot-wide strip running in front of the built-in cabinet, 
which has wood parquet. 

It is pleasant to have windows in an OB-GYN exam 
room. The wait is frequently very long and being able to 
look outside makes the wait a little more bearable. 
Polyvinyl chloride (PVC) vertical blinds serve exam rooms 
well since they permit light and view to enter the room 
while protecting the occupant's privacy. Narrow-slat hori- 
zontal metal blinds are also functional, but collect dust. 

Many physicians write a prescription in the exam room, 
but others ask the patient to dress and come to the con- 
sultation room. In any case, it is a good idea to provide a 
writing desk in the exam room so that the physician can 
make notations on the patient's chart and write a pre- 
scription, which may be done either manually or digitally. 



Minor Surgery/Special Procedures 

OB-GYN suites will have a minor surgery room where a 
variety of procedures will be performed (Figure 4-7). See 
also Figure 3-5, although it is not specifically set up for 
OB-GYN, the accompanying text addresses it. The plan in 
Figure 4-8 shows an ideal procedure room as it has an 
equipment storage room, a workroom for prep, cleanup, 
and sterilization, and natural light. The sink should be a 
large one with foot pedal control that can be used as a 
scrub sink. Special procedure rooms such as this always 




Figure 4-4. OB-GYN examination room. (Design: Jain Malkin Inc.; Photographer: Kim Brun.) 



Obstetrics and Gynecology 111 




Figure 4-5. OB-GYN examination room with cabinet at foot of exam table. (Casework design: Ashvin 
Contractor, San Jose, CA; Interior Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 





Figure 4-7. OB-GYN minor surgery room. [Design: Jain Malkin Inc.; 
Photographer: Kim Brun.) 



Figure 4-6. OB-GYN exam room, interior of casework. (Casework 
design: Ashvin Contractor, San Jose, CA; Interior Design: Jain Malkin 
Inc.; Photographer: Jain Malkin.) 



112 Medicine: Specialized Suites 



have a sink in them; however, it should be noted that oper- 
ating rooms such as may be found in plastic surgery or 
dermatology suites would not have a sink as regulatory 
agencies would view this as a breach of infection control. 
Sinks and drains are considered a potential source of 
pathogens. 

Types of Procedures 

The kinds of procedures that may be performed in this 
room include (if the gynecologist has a subspecialty in 
urology) cystoscopies; hysteroscopies (looking inside the 
uterus with a fiber-optic scope); D&Cs; colposcopies 
(examination of the cervix with magnification); and LEEP 
(loop electrosurgical excision procedure), which is the 
newest procedure to replace core biopsies. The colpo- 
scope (Figure 4-9) and all other equipment is portable. 
Sedation is not required, which negates the need for a 
recovery area. Suction (may be central or portable) is 
required in this room, but other medical gases are not. 
The room may have a video monitor (as explained in 
Chapter 3, Office of the Future) associated with the col- 
poscope or other fiber-optic scopes, in which case glare 
on the screen from windows or light fixtures may be a 
problem. The video monitor enables the patient to view 
the procedure and, with a printer, an image can be cap- 
tured as a still photo for future reference. With a telemed- 
icine connection, video images can be viewed at remote 
locations. Lighting in this room should be able to be 
dimmed if video monitors are used. 

Room Size 

The size of the room may vary from 12X14 feet to 14x16 
feet, depending on the number of assistants who must be 
in the room and the amount of medical equipment. 
Usually, an adjustable-height standard procedure table as 
in Figure 3-5 would be used. 

Ultrasound 

A common piece of equipment in an OB-GYN office is an 
ultrasound machine, which is used to observe the devel- 
oping fetus and also to image growths such as fibroids and 
cysts. It requires a trained sonographer. The room should 



52-0" 




OB-GYN 



2288 SF 

Figure 4-8. Space plan for OB-GYN, 2288 square feet. An ideal suite for one physician. 
(Design: Jain Malkin Inc.) 



Obstetrics and Gynecology 113 




Figure 4-9. Colposcope. (Photo cour- 
tesy: Welch Allyrf, Skaneates Falls, NY.) 



be located close to a bathroom, as women are usually 
asked to drink a large quantity of water prior to the proce- 
dure and, immediately after, will need to void. Although 
this equipment is portable, it is large (Color Plate 7, Figure 
4-10) and awkward to move from room to room. It is usu- 
ally placed in a large (10x12 feet) exam room that can 
also be used for standard examinations. A small ultra- 
sound unit (Figure 3-63) is becoming increasingly popular 
and can be tucked into a corner of a small exam room. Two 
guest chairs should be provided for family members who 
want to "experience" the heartbeat of the fetus. An ultra- 
sound room should have lighting that can be dimmed. 



Patient Education 

Many printed educational pamphlets are distributed, so 
suitable storage racks should be provided in the waiting 
room or in the corridor near the nurse station (Figure 
4-11). A provision should be made for patient education. 
It might be a niche off a corridor, which would have a built- 
in countertop with privacy partitions, a TV monitor, and a 
compartment under the countertop for a VCR as in Figure 
4-15. Patients would wear headphones. In lieu of this, one 
might provide a patient education room, preferably locat- 
ed near the front of the suite. 



Disposal of Infectious Waste 




Figure 4-11. Reading nook, women's clinic. (Design: Jain Malkin Inc.; 
Photographer: Kim Brun.) 



A large amount of trash is generated in this practice. A 
disposable gown, sheet, and exam table paper must be 
discarded after each patient, as well as paper hand tow- 
els and other disposable items. Each exam room should 
have a large trash receptacle, which may be built into the 
cabinet or freestanding. 

It should be noted that many cities, as well as OSHA, 
have regulations for dealing with infectious waste. These 
used to apply only to hospitals, but with the presence of 
HIV and other "super" viruses, medical offices are also 
required to separate their trash (refer to Chapter 3, OSHA 
Issues). Provision has to be made in the examination 



room for two receptacles. Paper from the exam table, 
paper towels, and wrappings from disposables could go 
into one container, and items coming into contact with 
patients' body fluids would be disposed of in a "red- 
bagged" infectious waste receptacle. (These bags must 
be labeled to indicate they contain infectious waste.) 



Specimen Toilets 

Since each patient must empty her bladder before an 
examination, an OB-GYN suite needs a minimum of two 



114 Medicine: Specialized Suites 



toilet rooms. If it is possible to locate the toilet rooms near 
the nurse station or lab (Figure 4-12), a specimen pass- 
through (see the Appendix) in the wall can eliminate the 
need for the patient to carry the urine specimen to the 
nurse station. Toilet rooms need a hook for hanging a 
handbag and coat, a shelf for sanitary napkins and tam- 
pons, and a receptacle for sanitary napkin disposal. It 
would be a nice touch to wallpaper the bathrooms. 



Laboratory 

The laboratory should be at least 10x12 feet and must 
include a sit-down space for a microscope and a coun- 
tertop space for centrifuge and an autoclave. Space 
should be allotted for an undercounter refrigerator. If the 
physicians elect to do a good deal of lab work in the suite, 
include a blood draw area and adequate countertop 
space for an automated clinical analyzer. The reader is 
referred to Chapter 3 for a discussion of CLIA regulations 
and an explanation of why physicians do little lab work in 
their suites these days. 



Interior Design 

Physicians in this specialty often like a well-appointed 
consultation room. Furnishings may be more elegant and 
refined than one might find in a consultation room of a 
general practice physician, for example. The room may be 
designed along the lines of a residential library or den, 
with a wood parquet floor and Oriental rug, bookshelves, 
fabric wallcovering, elegant upholstery fabrics, and an 
unusual desk. Window treatment, likewise, may be more 
like one would find in a residence rather than in a medical 
office. 

The waiting room, as well as the rest of the suite, ought 
to be designed to appeal to women. This may take the 
form of sunny colors and a garden theme with floral 
upholstery fabrics, or it may be elegant and sophisticated 
(Color Plate 8, Figure 4-13), perhaps a warm gray back- 
ground punctuated by polished chrome and Plexiglas fur- 



50'-0" 




OB-GYN 



1600 SF 

Figure 4-12. Space plan for OB-GYN, 1600 square feet. (Design: Jain Malkin Inc.) 



niture, dramatic lighting, accented by violet and char- 
treuse in the upholstery. 

If a physician's leanings are traditional, the style could 
be formal with wood moldings, Chippendale chairs with 
petit point upholstery, fabric wallcoverings, and Oriental 
rugs on a wood floor. Or, the traditional style might be less 
formal — country French. The options are many. This spe- 
cialty allows the designer a great amount of freedom; 
obstetricians and gynecologists usually like to present a 
well-decorated office to their patients. Whatever the 
design style, chairs should not be so soft or so low that it 



Obstetrics and Gynecology 115 



is difficult for pregnant women to disengage themselves. 
In summary, the patients here — due to the nature of the 
specialty — are generally happy, and this upbeat mood 
should be enhanced by the interior design. All rooms 
except the laboratory, minor surgery, and toilets may be 
carpeted. If the practice includes a number of women who 
are incontinent, exam rooms with hard-surface floors (e.g., 
wood-look sheet vinyl) may be more practical. 



WOMEN'S HEALTH CENTERS 

Women's health centers arose in the mid-1980s in 
response to various social and economic changes. Taking 
responsibility for one's own health, consumer education, 
questioning traditional medical practices, and a more 
assertive population of women who work outside the 
home were all contributing factors. When market analysts 
revealed the following, the magnitude of the women's 
market became evident: 



their own healthcare. There are no secrets. Patients are 
not kept waiting. Prices are quoted in advance. Lab test 
results — even normal ones — are related to the patient. 
During patient/physician consultations, the patient is 
clothed and seated at the same level as the physician. 
There is a special emphasis on making the patient feel 
like a welcome guest. 

Common to many women's centers is an all-female 
professional staff that may include family practitioners, 
internists, psychiatrists and psychologists, nurse practi- 
tioners, nutritionists, obstetrician/gynecologists, and 
social workers. These professionals focus their attention 
on gender differences in each area of specialization and 
thereby offer patients a measure of understanding that is 
sometimes lacking in healthcare provided by profession- 
als outside the women's center network. This is a major 
issue for women who are looking for continuity of care, 
instead of maintaining a relationship with five or six prac- 
titioners in different offices. 



• Women are the decision makers on family healthcare. 

• Women are the major users of medical and health 
services and, as women outnumber men in the popu- 
lation at large, they will continue to exert a major influ- 
ence on the marketing of healthcare services. 

• Women were often dissatisfied with the patronizing 
manner of some healthcare professionals. 

Motivated by a desire to meet the demands of this 
"new" consumer, healthcare providers have been courting 
women with marketing incentives that differ considerably 
from the traditional doctor-knows-best approach of former 
years. Promises of no waiting, evening and Saturday 
office hours, convenient parking, child care, and health 
education seminars are attractive incentives. 

These are not the only things that draw women to 
these facilities. The attitude of the staff is often dramati- 
cally different in a market-driven practice than in the tra- 
ditional healthcare setting. There is an expressed respect 
for women and an opportunity for them to participate in 



Psychological and Mental Health Issues: 
Refocusing the Primary-Care Agenda 

The women's primary-care agenda shifted in the 1990s 
as sex and gender-specific aspects of primary care 
became a focus of academic medicine. Research and 
policy-making organizations staged conferences to 
define pressing issues in women's health, and a fairly 
clear picture emerged. The real needs of many women 
were underserved. Victims of rape, incest, domestic vio- 
lence, poverty, drug abuse, and various mental disorders 
often had no access to appropriate care and still don't in 
2002. Many of these issues must be approached from a 
community health perspective, taking into account cultur- 
al or ethnic factors. 

As the decade of the 1980s progressed, the changing 
roles of women added additional psychological stresses, 
resulting from balancing child care, work outside the 
home, spousal relationships or divorce, and care of aging 
parents. This was often referred to as the "superwoman 
syndrome." These issues continued unabated into the 



116 Medicine: Specialized Suites 



1990s with even more pressure to be successful, provide 
well for one's children, and participate in the booming 
economy. Men and women in the 1990s worked even 
longer hours; consumer spending soared, as did the 
number of self-help books promising a plan for balancing 
one's life. A new term, the "sandwich generation," gave 
recognition to the pressures of child care on one side and 
parent care on the other, as the U.S. population continues 
to push toward having the largest number of centenarians 
in the history of the world. It is a well-established fact that, 
whether for one's own parents or one's in-laws, it is the 
female — sister or wife — to whom elder care usually falls. 
Summarizing the lesser-known gender-specific issues 
arising from the research of the last half of the 1990s 
reveals the following: 

• Women's unique requirements for health and well- 
being have been largely ignored by the healthcare sys- 
tem. 

• Gender-specific care is far more than that which deals 
with the female reproductive system. Being female is 
not the same as not being male. The distinction 
between sex and gender is crucial. Sex refers to chro- 
mosomal structure, while gender is what society and 
culture make of those biological characteristics*. 

• There is a vast unmet need for mental health screen- 
ing, assessment, and treatment in the primary-care 
setting as an integral part of core services. 

• A full-service women's center removes some of the 
social barriers and stigma associated with accessing 
mental healthcare. 

• Women access mental health services through their 
primary-care provider. Many women with mental health 
problems never see a mental health professional. 

• Safety and confidentiality are huge issues in mental 
health treatment for women. 



*S. R. Kunkel and R. C. Atchley, 1996. American Journal of Preventive Medicine 
12(5):295. 



Women access mental health services through a 
women's center because their problems are taken seri- 
ously. 

In the traditional primary-care setting, women's mental 
health issues are often misdiagnosed as physical dis- 
eases by physicians whose biomedical training does 
not enable them to identify the psychosocial genesis of 
the symptoms. 



Translating Women's Primary-Care Needs 
to the Built Environment 

The overarching need to create a safe haven, a psycho- 
logically supportive care environment that makes women 
feel secure and comfortable can best be achieved by a 
women's center, a place where women do not encounter 
men in the waiting room. Interior design should be based 
on research aimed at reducing stress. Research exists in 
five principal areas to inform design decisions: 

• Connection to Nature: Even a three-minute view of 
nature in the form of a garden or water element (or 
even a realistic photograph of nature) has been shown 
to have immediate physiological benefits in terms of 
stress reduction. These features can be incorporated 
into waiting areas and treatment settings. Natural light 
in as many rooms as possible is desirable. 

• Pleasant Diversions: Music, aromatherapy, an aquari- 
um, engaging pieces of art or sculpture all address the 
multisensory nature of human beings. Moments of joy 
and delight distract patients from pain and help them 
cope with the burden of illness. 

• Social Support: Although this is not a design issue, 
compassionate caregivers, social worker/case man- 
agers, and peer support groups enhance well-being 
and foster coping skills. 

• Elimination of Environmental Stressors: Noise, lack of 
privacy, overheard conversations, poor air quality, and 
glare from inappropriate lighting design create stress 



Women's Health Centers 117 



for patients and caregivers alike. These are features of 
the built environment that can be controlled by compe- 
tent design professionals. 

Options and Choice: Whether it is the selection of 
alternate styles of seating in the waiting room, options 
for things to do while waiting, passive or active partici- 
pation in one's healthcare, or access to a resource 
library, providing options greatly reduces stress. 



Customer Service Focus 

Some of the newly opened centers are affiliated with a 
hospital, but other clinics are operated by physicians or 
entrepreneurial for-profit corporations. The for-profits tend 
to operate their facilities with an eye on the bottom line — 
that healthcare can be packaged and delivered as a prod- 
uct and earn a profit at the same time. Viewing healthcare 
as a business, rather than as a community service, makes 
the for-profits particularly sensitive to marketing trends 
and customer satisfaction. This is good news for design- 
ers. A client who is aware of marketing opportunities 
understands that the design of the facility will attract 
patients and, in turn, will lead to many patient referrals. 

Women find these facilities comfortable and nonclini- 
cal, with carpeted floors, wallcoverings, and residential- 
style lighting and furniture. Clients who are attentive to 
these issues may actually reduce their marketing costs 
due to increased referrals by satisfied patients. 



Design and Planning Issues 

To design a women's health center properly, one has to 
understand the range of services offered — and this varies 
from facility to facility. These may include gynecology, 
mammography, osteoporosis screening, primary care, 
internal medicine, diet and exercise programs, nutrition 
counseling, weight loss clinics, counseling on family or 
social problems, and prenatal care. Great emphasis is 
placed on prevention and patient education. Seminars and 



lectures by healthcare experts occur regularly. Other fea- 
tures may include a library or reading area for information 
on healthcare topics. 

Those who plan women's health centers should con- 
sider the following: 

• Secure parking, close to the building entrance. 

• Understandable wayfinding: entrances clearly marked, 
no maze-like internal corridors. 

• Privacy issues addressed in all settings: 

Reception check-in 

Those waiting should not overhear telephone or 

other conversations with or about other patients. 
Exam room integrity: Patient should not be able to 

overhear conversations in adjacent exam rooms. 
Secure dressing areas. 

• Include children's play spaces in waiting rooms. 
Arrange seating in waiting rooms in privacy groupings, 
broken up by low planter walls so that patients are not 
forced to stare at each other. 

• Include in waiting rooms a self-serve coffee/tea bar, 
areas to plug in computers, a fax machine, a free 
phone for local calls. A TV should not dominate the 
room — it causes stress for those who are forced to 
watch offensive programming. If long waits are 
inevitable, provide a pager to allow patients to sit out- 
doors in a garden or browse in nearby shops as appro- 
priate. Provide a variety of current magazines address- 
ing diverse interests. 

• Small vases with a fresh flower in exam rooms, colored 
gowns, a magazine rack, a mirror for checking one's 
hair or makeup before exiting, and a proper place to 
store one's clothes indicate an attention to detail that 
reinforces confidence in the clinical care (Figure 4-4). 

• A kitchen for nutritional counseling and food prep 
demonstrations is included in some women's centers. 

• Color and design should appeal to women, but not be 
overly frilly. Too often, facilities try to appear "feminine" 



118 Medicine: Specialized Suites 



by using inexpensive French Provincial furniture, velvet 
cushions, or artwork framed with ruffles and lace. This 
may appeal to some women, but the majority may pre- 
fer a more sophisticated treatment (Color Plate 8, 
Figure 4-14). 

The reception window should be wide and open so that 
the patient does not feel closed out and isolated. 

Patient education carrels should be located in view of 
one of the receptionists, but should afford privacy for 
the patient (Figure 4-15). 

A large multipurpose meeting room is needed for lec- 
tures and seminars. It should be furnished with tablet- 
arm chairs and a number of small tables that can be 
pushed together for meetings (Figure 4-15). 

Exam rooms need dressing cubicles for patient privacy 
and for hanging clothing. Medical equipment and 
instruments should be stored out of sight so that the 
room appears nonthreatening to the patient. Exam 
rooms (except those used for minor surgery) should be 
carpeted. It should be noted that recent developments 
in commercial carpet fibers and backings as well as 
antimicrobial and stain-resistant properties make car- 
pet a viable option for exam rooms. 

The physician's consultation room or private office 
should have — in addition to a desk — some lounge 
chairs or a small sofa and coffee table to provide an 
informal, friendly, residential setting. 

A library, if space allows, can be located in a separate 
room or in a nook off the entry, but within view of the 
receptionist or cashier. For brochures, which are meant 
to be handed out, a rack in the reception area or corri- 
dor would be sufficient (Figure 4-11). 

The scale at the nurse station should be placed to afford 
privacy for those self-conscious about their weight. 
Ample storage areas for drug samples and other items 
must be provided in the nurse station, as well. 

One room will be a breast exam room, which means 
that the patient will usually lie down on a divan or high 



59'-6' 




Uj ARCH (TW.) 

TECH AREA 



SECONDARY 
WAITING 




a ■ a 

PATIENT ED. 



NURSES 
STATION Q 




fcte 


I 


^//hxJtI^t.i 


LIBRARY 


k 



XHECK-OUT 





TO PUBLIC 
RESTROOMS 



WOMEN'S HEALTH CENTER 

3450 SF 



Figure 4-15. Space plan for women's health center, 3450 square feet. (Design: Jain Malkin Inc.) 



Women's Health Centers 119 



bed and watch a video describing how to do a breast 
self-exam. There also needs to be a chair for a nurse 
or aide. 

Light fixtures should not shine into patients' eyes; 
therefore, alternatives such as wall sconces, wall 
washers, indirect perimeter lighting, or low voltage 
downlighting should be used (Color Plate 9, Figure 
4-1 6). Limit the use of lay-in 2x4 fluorescent lighting in 
examination or treatment rooms. 

If the facility is to be staffed primarily by women, the 
height of such items as X-ray view boxes, countertops, 
and cabinets must be considered. The average height 
of a woman is 5 feet, 4 inches. 

Patients appreciate a specimen pass-through between 
the restroom and lab so that the patient does not have 
to carry the specimen into the corridor. 

Cabinets in the minor surgery room can house large 
pieces of equipment, such as the suction machine, the 
colposcope, and the emergency crash cart, which tend 
to be anxiety-provoking items (Figure 4-7). More case- 
work is needed here compared with a standard exam 
room. Also, the floor should be sheet vinyl or other eas- 
ily cleaned material. 

For acoustical privacy, exam rooms should have solid- 
core doors, Fiberglas® insulation batting in the walls, 
and walls that continue above the finished ceiling. 



A Women's Center for the Millennium 

Much has been written about the effects of the Internet on 
culture and the economy. Instant wealth for many individ- 
uals — especially those under the age of 25 — has been a 
unique occurrence as has instant access to information. 
One thing is certain: two forces — the Internet and the 
Baby Boomer generation — will create seismic change in 
our institutions, in the way we define aging, and in what 
we expect from our healthcare system. 



A women's center for the first decade of the new mil- 
lennium will address the full continuum of women's health 
and, with the huge number of Baby Boomer women in 
their mid-50s, the focus on postmenopausal issues may 
exceed the prior emphasis on birthing. The significant 
increase in persons living to the age of 100 and the over- 
all Baby Boomer emphasis on healthy lifestyles requires 
educational programs relating to aging. 

Marketing to women and making sure that they have a 
pleasant experience is especially important for women's 
centers associated with a hospital as it's usually the 
woman who decides where her family will access care. In 
fact, various market research sources indicate that 
women make between 80 and 84 percent of healthcare 
decisions in the United States. Women communicate dif- 
ferently than men and approach illness from different 
points of view, yet these subtle differences are often 
ignored. Understanding women's unique requirements for 
health and well-being will increase market share and 
establish loyalty. 



BREAST CENTERS 

Historically, mammography screening has been available 
to women in diagnostic imaging (radiology) centers and, 
occasionally, in the offices of large OB-GYN practices. In 
recent years, however, more comprehensive breast care 
services have been provided in specialized facilities that 
offer women more psychosocial support and a full range 
of services, should they be diagnosed as symptomatic. 
Even when mammography is part of a diagnostic imaging 
suite, the goal is usually to separate it from the other 
imaging modalities, creating a separate entrance and 
identity (Figures 5-4 and 5-5). 

Depending on the anticipated volume of procedures 
and the potential as a feeder to oncology services, the 
breast center may be totally independent of diagnostic 
imaging, having its own ultrasound, mammography, and 
stereotactic rooms, as well as film filing and reading 
areas. The proliferation of well-designed, high-profile 



120 Medicine: Specialized Suites 



breast centers in recent years is a reflection of the 
increased awareness of the benefits of early detection as 
well as a response to reaching out to women who make 
most of the healthcare decisions for their families. 

The scale and range of breast care centers is 
demonstrated by the small facility in Figure 4-18 and 
the somewhat larger one in Figure 4-17, both associat- 
ed with a community hospital but located in an MOB; 
Figure 6-6, associated with a large primary-care clinic; 
Figure 4-19, also under a hospital's license but located 
in a medical office building with direct access to an 
ambulatory surgical center; and the largest of these 
facilities (Figure 4-38) is part of a cancer center, which 
includes chemotherapy infusion, also associated with a 
large community hospital, but located in a campus 
MOB. Interior photos of all of these facilities are includ- 
ed in the book and will be cross-referenced later in this 
discussion. Some have been placed in the Oncology 
section, others here in the Breast Centers section, and 
a few appear in Chapters 6 and 13. All of these facilities 
have outstanding design features in addition to being 
highly functional in terms of space planning and critical 
adjacencies. 



[Image not available in this electronic edition.] 



Psychological Context 



The possibility of breast cancer strikes such a chord of 
fear and terror in many women that the anticipation of 
having a mammogram is filled with dread. This, despite 
the fact that more women die of heart disease every year 
than breast cancer. Understanding this context of fear of 
the unknown, and perhaps the subconscious fear of the 
possibility of losing a breast if a lesion or tumor is dis- 
covered, causes some women to arrive at the facility in 
an anxious state of mind. Therefore, a design that is 
calming and soothing will be appreciated. Research 
shows that connecting people to nature with a view of a 
garden, or a water element like a large fountain, and nat- 
ural light has immediate physiological benefits in terms of 
reducing stress. Even a simulated view of nature as in 



Figure 4-17. Space plan, 3495 square feet. Memorial Breast Care Center at Anaheim Memorial Hospital, Anaheim, 
CA. (Architecture and interior design: Taylor & Associates Architects, Newport Beach, CA.) 



Breast Centers 121 



[Image not available in this electronic edition.] 



Figure 4-18. Space plan, 8436 square feet. Hoag Hospital Breast Care and Imaging Center. (Architecture and interior design: Taylor & Associates 
Architects, Newport Beach, CA.) 



Color Plates 9, 25, and 28, Figures 4-20, 5-70, and 7-15, 
respectively, is effective. Providing options and choice 
also reduces stress. Patients who visit the Scripps Breast 
Care Center (Figures 4-19 and 4-21 and Color Plates 10, 
11, Figures 4-22, 4-23, and 4-24) have a choice of five 
options to fill their time while waiting for the procedure. 
After gowning, they may sip tea from a china tea service 
and read magazines; watch a video on breast self-exam; 
visit the resource library to select a book or video (using 
wireless headphones) or go on line to research women's 
health topics; tour the corridors to see the many works of 
art and contemporary crafts; or visit the positive appear- 
ance center to select a gift. Pleasant diversions, accord- 
ing to research, also reduce stress. These include aquar- 
iums (Figure 4-50), fountains, soothing music, interactive 
works of art, or anything that distracts one from worry 
and fear. 



Psychological Support 

One of the advantages of screening at a breast center, as 
opposed to having a mammogram at a diagnostic imag- 
ing facility, is the psychosocial support that is often avail- 
able to women who prove to be symptomatic. In the typi- 
cal scenario, a woman who learns she has a suspicious 
growth has to wait an agonizing week or two to book an 
appointment with a primary-care physician who will likely 
refer the patient for further diagnostic studies. That inter- 
val of time can be torturous, whereas, in a breast center, 
psychosocial support is immediately available through 
counselors and nurses. Further diagnostic tests can be 
conducted at the same site with care coordinated by a 
concerned and familiar team of individuals. A connection 
to the breast center can be maintained even after surgery 
and other types of therapy, by virtue of counseling and 
educational programs as well as support groups. 



122 Medicine: Specialized Suites 



STAF ENTRY 




SCRIPPS BR EAST CARE CENTER 

8800 SF 

Figure 4-19. Space plan, 8800 square feet. Scripps Breast Care Center, La Jolla, CA. {Architecture and interior Design: Jain Malkin Inc.) 



1 RECEPTION 

2 RESOURCE LIBRARY 

3 ROTUNDA 

4 BUSINESS OFFICE 

5 WORKROOM 

6 POSITIVE APPEARANCE CENTER 

7 EAST OF THE SUN LOUNGE 

8 WEST OF THE MOON LOUNGE 

9 DRESSING ROOMS 

10 RESTROOM 

11 VOLUNTEER'S OFFICE 

12 PATIENT EDUCATION / EXAM 

13 MAMMOGRAPHY ROOM 

14 MEDICAL DIRECTOR 

15 ADMINISTRATOR 

16 NURSES' OFFICE 

17 STEREOTACTIC 

18 ULTRASOUND 

19 WORKROOM 

20 DARKROOM CHEMICALS 

21 DARKROOM 

22 TECH WORK CORRIDOR 

23 CONFERENCE ROOM 

24 FILM READING 

25 RADIOLOGISTS' OFFICE 

26 STAFF LOUNGE 

27 STAFF LOCKER ROOM 

28 PRE-OP CONSULTATION 



Breast Centers 123 




Scope of Services 

Screening and Diagnosis 

• Screening and diagnostic mammography 

• Clinical breast examination 

• Ultrasound and ultrasound-guided biopsy 

• Stereotactic-guided core biopsy 

• Stereotactic-guided mammotomy biopsy 

• Needle localization biopsy 

Education and Outreach 

• Education in breast self-examination and breast health 

• Positive appearance center with wigs, scarves, hats, 
and prostheses 

• Resource library with Internet access and guidance 

Wellness Programs 

• Healthy lifestyle programs 

• Nutrition counseling 

• Complementary therapy resources 

Professional and Support Services 

Peer survivor program ("buddy" matching) 

Support groups 

Genetic risk assessment and counseling 

Patient and family education 

Multidisciplinary pretreatment planning conferences 

Second-opinion consultation services 

Lymphedema/rehab services 



Figure 4-21. Ethel Rosenthal Resource Library. Scripps Breast Care Center, La Jolla, CA. (Interior 
architecture and Design: Jain Malkin Inc.; Photographer: Glenn Cormier.) 



124 Medicine: Specialized Suites 



Space Planning Considerations 

The space planner may wish to consider these space- 
planning features: 

• Lay out procedure rooms with separate entries for tech 
and patient: techs enter rooms from a tech work corri- 
dor that includes workstations, view box, and access to 
darkroom (Figures 4-18 and 4-19). 

• Locate closet for darkroom chemicals close to rear 
entry of suite so that deliveries can be made without 
having to walk through suite with hand cart; pipe chem- 
icals through wall to darkroom (Figure 4-19). 

• Instead of a conventional reception window, consider 
using a concierge desk, staffed by a volunteer, in the 
main lobby to greet and check in patients (Color Plate 
10, Figure 4-22). 

• If possible, provide a connection to a surgery center. 
This provides the greatest privacy and convenience 
for women who have had a needle localization 
and now have to proceed to surgery for biopsy 
(Figure 4-19). 

• Separate "screening" mammography patients from 
"symptomatic" in gowned waiting (Figure 4-19 and 
Color Plate 1 1 , Figure 4-24). 

• Provide a separate and identifiable entry when part of 
a larger clinic setting (Figures 4-38 and 6-6). 

• Provide acoustically and visually isolated (from 
patients) staff area with lounge, conference room, rest- 
rooms, film reading, film filing, and offices for radiolo- 
gists and medical director (Figures 4-18, 4-19, 4-38, 
and 6-6). 

• Provide a resource library near the lobby (Figures 
4-19, 4-21, and 6-6). 



Interior Design Amenities 

Provide wall sconces and other indirect lighting in all 
procedure rooms as well as exam/patient education 
rooms (Figure 13-3). 

Consider a painting for the floor under the stereotactic 
table (protected by piece of Lexan®), where patient is 
lying on stomach, looking down. 

Furnish the lobby or waiting room like a living room 
with a variety of seating, interesting ceilings, lighting, 
and artwork (Color Plates 1 1 and 26, Figures 4-24 and 
6-8, respectively). 

Even a small waiting room can become an extraordi- 
nary work of art by virtue of geometry, ceiling design, 
lighting, and use of color (Color Plate 40, Figure 13-8). 
Consider a separate lounge for the men who often 
accompany patients. 

An intimate, serene inner sanctum was created in a 
challenging below-grade space with low ceiling and no 
windows, by building banquette seating around the 
perimeter, complemented by exquisite detailing, care- 
ful attention to lighting, and a few surprises such as the 
opening in the ceiling (Color Plate 12, Figure 4-25). 

Provide elegant, private dressing rooms (Figure 4-26). 

A considerable amount of literature is dispensed, 
which requires racks to keep it sorted and neat 
(Figures 3-1 1,4-11, 4-91 , and 12-3). 

Include pleasant diversions to reduce stress such as a 
large aquarium (Figure 4-50) and trompe I'oeil (French 
for "fool the eye")-style murals (Color Plates 9 and 18, 
Figures 4-20 and 4-101, respectively). 

In oncology consultation rooms, consider building into 
a table, an audio cassette recorder to enable a patient 
to record the physician's comments to replay later at 
home. In the anxiety of the moment, it's easy to forget 
what was said. 



Breast Centers 125 



[Image not available in this electronic edition.] 



Figure 4-26. Dressing room. Hoag Hospital Breast Care and Imaging Center. 
{Architecture and interior design: Taylor & Associates Architects, Newport Beach, CA; 
Photographer: Farshid Assassi.) 



Gowned waiting can be designed as a living room with 
an inset area rug and an opening on one or two sides 
to provide a view of something interesting. The suite 
plan in Figure 4-19 provides two 18-foot-diameter 
gowned waiting rooms, one for screening mammogra- 
phy patients and the other for symptomatic patients. 
Derived from a popular Norwegian fairy tale, the West 
of the Moon lounge (Color Plate 11, Figure 4-24) 
opens, on one side, to a view of three large oil paint- 
ings commissioned by an artist to represent the three 
phases of a woman's life: the young maiden, the nur- 
turing mother, and the wise elder. They combine sym- 
bolism such as a butterfly for metamorphosis, a lotus 
flower representing higher consciousness, and they 
also incorporate the sun and the moon, the two 
themes of the gowned waiting lounges. Another open- 
ing in the room exposes a view of a carved granite 
fountain that looks like a large boulder. 

Consider a "theme" to anchor the design. As an exam- 
ple, the aforementioned gowned waiting areas are 
developed around the sun and the moon. The lounge 
for symptomatic patients, named East of the Sun, cel- 
ebrates the summer solstice, which research indicates 
has, for centuries, been regarded as the peak of 
women's energy and healing. It is much celebrated in 
Northern Europe. The ceiling (which is round) has a 
cut in it similar to a sundial marker pointing northwest, 
exactly where the sun would be on June 21 . It, as well 
as a marker in the inset carpet design, points to a 
recessed niche with a custom sculpture of a sundial 
and text explaining the concept. The other lounge, 
West of the Moon, is dedicated to the Triple Goddess 
of the Moon legend that can be found in many cultures, 
tying the phases of the moon (waxing, full, waning) to 
the three phases of a woman's life. In this lounge, a 
recessed niche with a custom sculpture represents this 
concept. The three large paintings and the concepts for 
the two lounges are mutually reinforcing. In addition, 
the 12-foot-diameter entry rotunda (Color Plate 11, 
Figure 4-23) introduces Hygeia and Panacea, daugh- 
ters of Aesclepius, the god of healing in 4th century 



126 Medicine: Specialized Suites 



b.c. Greece, representing, respectively, prevention and 
treatment. They welcome women to the Scripps Breast 
Care Center. 

Locate the positive appearance center near the front of 
the suite as this is a retail space. 

Historically, facilities designed specifically for women 
have often had period-style furniture and somewhat 
frilly decor. Determined to demonstrate a more modern 
approach, the architect for the Anaheim Memorial 
Breast Center combined soft pastel colors with con- 
temporary architectural forms such as cantilevered 
glass panels and strong ceiling elements that intersect 
each other and connect one space to the next (Figure 
3-18 and Color Plate 40, Figure 13-8). Note the elegant 
sandblasted pattern on the glass. The Scripps Breast 
Care Center also departs from expectations about 
appropriate colors for a breast center. The geranium 
red accent used throughout (the most auspicious color 
in feng shui) is a counterpoint to the warm gray walls 
and carpet. The stereotactic room in Color Plate 13, 
Figure 4-27, is a welcome change from the cold, clini- 
cal VCT floor environments one typically encounters. 
The wood-grain sheet vinyl and maple casework, com- 
bined with two complementary colors (violet and yel- 
low), create a soothing ambience. The lavender border 
has metallic silver spirals known as the "Archimedes 
spiral," which Carl Jung identifies as one of the earliest 
forms associated with healing in many cultures. 



Correlation of Suite Plans and Photos 

Because all of the facilities featured have high-profile 
design that should be correlated to the respective space 
plans, following is a list of locations of interior photos. 

Suite plan Figure 4-17: Figure 3-18 and Color Plate 40, 
Figure 13-8 

Suite plan Figure 4-18: Color Plate 12, Figures 4-25 
and 4-26. 



Suite plan Figure 4-19: Figures 3-23, 4-20, 4-21, Color 
Plates 1 0, 1 1 , and 1 3, Figures 4-22, 4-23, 4-24, and 4- 
27, and Figures 4-28, 4-30, and 5-20. 

Suite plan Figure 6-6: Color Plate 26, Figure 6-8 



Explanation of Treatment Modalities 

Mammography 

An X-ray is taken of the breast, which is compressed 
between two horizontal plates. The control screen that 
protects the tech is usually integrated into the equipment 
(Figures 4-28 and 4-29). The room often has a sink cabi- 
net and may have a desk for the tech. There are no 
restrictions about finishes in this room with carpet and 
wallcovering having become standard. Some mammog- 
raphy rooms are quite elaborate in their interior design 
features, incorporating crown moulding and commis- 
sioned works of art. 

Stereotactic 

In this room, the patient lies on her stomach on a special 
table with an opening through which the breast pro- 
trudes. To accommodate staff, the table is high. The 
breast is compressed on a panel while two stereotactic 
X-rays (taken from two different angles) are taken. The 
precise location of the suspicious lesion is analyzed by a 
computer based on the X-rays. Following this, a device 
that will direct a probe and needle into the breast is posi- 
tioned by the computer at the proper angle. The target 
area is deadened with a local anesthetic. The needle has 
a notched opening on the tip that cuts a small amount of 
breast tissue while a vacuum pulls the tissue into the 
probe. A machine equipped with a new device called the 
Mammotome™, manufactured by Biopsys Medical Inc. in 
Irvine, California, enables the physician to obtain several 
tissue samples within a full circle with only one needle 
insertion, as opposed to several when doing core-needle 
biopsy. The stereotactic room can also used for needle 
localizations prior to surgical biopsies. Typically, the nee- 



Breast Centers 127 




Figure 4-28. Mammography room. Scripps Breast Care Center, La Jolla, CA. (Interior architecture and Design: Jain Malkin Inc.; Photographer: Glenn Cormier.) 



128 Medicine: Specialized Suites 



die is placed and a paper cup is put over it to protect it 
while the patient dresses and drives to an ambulatory 
surgical center for the biopsy. This is inconvenient and 
most likely adds to the patient's anxiety. If direct access 
to a surgery center is possible, as in Figure 4-19, it is 
optimal. 

Ultrasound 

Used as an adjunct to mammography and physical exam- 
ination, ultrasound helps physicians decide if a biopsy is 
necessary for suspicious breast lesions by providing more 
information about whether the "area" is a cyst or a solid 
mass. The ATL High Definition™ Digital Ultrasound, 
according to the manufacturer, may reduce the number of 
surgical breast biopsies by 40 percent, is less costly than 
surgery, and does not cause internal scarring. The afore- 
mentioned Mammotome device is also compatible with 
ultrasound equipment, allowing the physician to position 
the probe in the exact spot where tissue acquisition is 
desired. Refer to the Obstetrics and Gynecology and 
Women's Health Center sections for discussion of lighting 
and layout of ultrasound rooms. Also see Figures 4-10 
and 4-30. 



Tech Areas 

Ideally, patients will not see other patients' X-rays mount- 
ed on view box illuminators, nor will they overhear staff 
conversations to ensure patient confidentiality. The tech 
corridor in Figure 4-19 provides entry into all procedure 
rooms as well as access to the darkroom. Placed conve- 
niently outside each procedure room are stand-up-height 
viewing areas to enable techs to check films. Remember 
that the techs in a breast center are all women, which 
means casework, countertops (with vertical slots under- 
neath for sorting X-rays), and mounting heights for stand- 
up view boxes must be appropriate for the average 5-foot- 
4-inch-high woman. 

The radiologist will most likely use film alternators in 
the reading room (Figure 5-22). Radiologists will some- 




Figure 4-29. Mammography room. Saint Jude Breast Center. {Architecture and interior design: Haynes and 
Oakley Architects, Sierra Madre, CA; Photographer: John Connell Photography.) 



Breast Centers 129 




Figure 4-30. Ultrasound room. Scripps Breast Care Center, La Jolla, 
CA. {Interior architecture and Design: Jain Malkin Inc.; Photographer: 
Glenn Cormier.) 



times request cubicle drapes or some other means of 
partitioning to control distractions. The film viewing area 
should be in the quietest part of the suite and will be adja- 
cent to the radiologist's office. A large conference room is 
common to these facilities as there are numerous staff 
conferences regarding treatment planning and case pre- 
sentations. 



Donor Opportunities 

Breast care centers are valued highly by hospital founda- 
tions because they are highly visible and attractive to 
donors. If the facility has a high-profile design that distin- 
guishes it, it is astonishing the amounts of money that can 
be raised to name individual rooms, the lobby, the positive 
appearance center, and the facility itself. A high-profile 
center may cost $1 00 per square foot in 2001 to construct 
(tenant improvement cost), but can attract $5 to $10 mil- 
lion in underwriting, depending on the geographic loca- 
tion, the foundation's outreach and skill, the prestige of 
the physicians associated with it, and the unique design 
properties of the facility. 



REPRODUCTIVE ENHANCEMENT 
(ASSISTED REPRODUCTIVE TECHNOLOGIES) 

Overview 

Who would not be smitten by the emotional context that 
surrounds this ultra-high-technology specialty? The 
hopes and dreams of so many to have a family are linked 
to a successful outcome and the fact that it all happens 
within the walls of this facility — life is created here. 
Couples, singles, both heterosexual and homosexual, 
and occasionally individuals who travel from remote parts 
of the world find their way to the portals of the most cele- 
brated and clinically successful specialists in reproductive 
enhancement. This is a relatively new field that has been 
much in the news in recent years with articles celebrating 
the astonishing technological accomplishments, which 
are, at times, flanked by controversy surrounding multiple 
births, surrogates who later decide to keep the baby 
themselves, frozen eggs that have been stolen and sold 
without the donors' knowledge, and eggs that have been 
carelessly handled and transplanted into the wrong per- 
son. Registries have sprung up on the Internet offering, at 
exorbitant prices, "designer" eggs and sperm of individu- 
als who exemplify an aesthetic ideal, have very high SAT 
scores, or are gifted musicians, athletes, or high achiev- 



130 Medicine: Specialized Suites 



ers at Ivy League schools. Despite this backlash, the 
need to pass on one's genes and to procreate is among 
the most primal of nature's urges and, as this specialty 
matures, the Brave New World queasiness will no doubt 
subside. These procedures are a touchstone for moral, 
ethical, and spiritual conflict as society attempts to grap- 
ple with what a mere 15 years ago would have been con- 
sidered science fiction. 

Access to Information 

The Internet is a tremendous source of information on 
infertility treatments with a surprising number of Web 
sites by assisted reproductive technologies that read 
more like medical textbooks. This means that patients 
may arrive at the physician's office with a highly sophisti- 
cated understanding of all of the techniques, success 
rates of each, and sheaf of journal articles. 



Psychological Considerations 

One could say that everything associated with these pro- 
cedures creates stress. In the words of Elizabeth Barrett 
Browning, ". . . let me count the ways," starting with what 
brings individuals to seek this sort of help — years of 
yearning and trying to conceive. Couples deal with guilt, 
blame, worry, and hope, living by ovulation cycles, and the 
optimum day to "do it," and what started out as pleasura- 
ble sex has become fraught with anxiety, akin to a project 
or a job. The pressure is tremendous. And women, at 
some point, feel that biological clock running out of time. 
Once one enters reproductive therapy, there are no 
guarantees or magic bullets. One enters the world of crit- 
ical timetables, cycles, and many steps in a process that 
are dependent on each other. Failure at any stage may 
mean aborting the process and starting over. Consider 
the highs and lows of waiting for news about results of 
blood tests, sperm motility, viability of the eggs, and 
whether fertilization has taken place. Add to this the hor- 
monal changes resulting from fertility drugs that can 
cause strong emotions and unpredictable outbursts. 
Trying to conceive is a stressful process and infertility 



treatment an ongoing enterprise. With all the magic asso- 
ciated with a successful outcome, the day-to-day reality 
of the ordeal can be physiologically and psychologically 
grueling. To help individuals and couples manage these 
emotions, counseling sessions teach coping skills, stress 
management, and relaxation techniques. The financial 
impact of infertility treatment is substantial. Individuals 
who have tried unsuccessfully for several years to con- 
ceive may have mortgaged their homes, borrowed from 
friends and family, sold their automobile, to be able to 
continue with the treatment. This compounds the emo- 
tional stress. 

Designing for Comfort 

Designing to meet patients' psychological needs in this 
specialty leads one to think of comfort in every conceiv- 
able manner. One would avoid sharp angles, geometric 
forms that create visual tension, high levels of illumina- 
tion, hard, shiny, surfaces, materials that are cold to the 
touch, and seating that is lined up like soldiers against the 
wall. Granted that design and color are always, to a cer- 
tain degree, subjective, and what constitutes comfort may 
be open to interpretation. Nevertheless, one should strive 
to create a serene environment, with a variety of seating, 
including some oversized chairs that metaphorically form 
a cocoon around a person. Employ a soothing color 
palette leaning toward warm, rather than cool, colors. 
Wood can be used on the face of the reception desk and 
elsewhere to add warmth (Figure 13-4). Walls and ceil- 
ings may have curved forms, and lighting should be var- 
ied, avoiding entirely 2x4-foot lay-in fluorescent lumi- 
naires (Color Plate 13, Figure 4-31, and Figure 13-7). 
High levels of illumination and glare can create tension. 

Artwork used in the waiting room must be selected care- 
fully. One must avoid anything that might hit a nerve such 
as photos of parents and children, although there are 
places in the office where this can be quite successful as 
relevant art, but not in the waiting room. Art that is whimsi- 
cal can be quite successful. In Color Plate 13, Figure 4-31 , 
an artist was commissioned to create a series of five 
gouache and pastel pieces reminiscent of Cirque du Soleil 
characters. These are placed along one wall; on the oppo- 



Reproductive Enhancement (Assisted Reproductive Technologies) 131 



site wall are actual Cirque du Soleil sculptures and other 
whimsical works of art. Be mindful that art images should 
not represent what appears to be overweight female forms 
because women undergoing hormone therapy for infertility 
experience water retention, they feel bloated, and their 
ovaries may actually triple in size. 



Procedures and Terminology 

A few years ago, this field was often referred to as IVF, or 
in vitro fertilization, but, as the field has become more 
technologically advanced and an expanded number of 
services are offered, assisted reproductive technologies 
(ART) is the preferred term. 
Assisted reproductive technologies include the following: 

• Infertility diagnosis prescreening 

• Artificial insemination — large numbers of washed 
motile sperm are placed into the female reproductive 
tract, often the uterus 

• Intrauterine insemination (IUI) — sperm are placed 
directly into the uterus 

• Hormonal therapy to induce ovulation 

• Reproductive laser surgery to treat endometriosis and 
other uterine or tubal problems that can affect fertility 

• Ovulation induction with artificial insemination 

• Gamete intrafallopian transfer (GIFT) — eggs and 
sperm are injected directly into the woman's fallopian 
tubes via laparoscopy 

• Zygote intrafallopian transfer (ZIFT) — a zygote (newly 
fertilized egg) is inserted directly into the woman's fal- 
lopian tubes 

• Intracytoplasmic sperm injection (ICSI) — using micro- 
manipulation technology, a single sperm is injected 
into the center of the cytoplasm of the egg to achieve 
fertilization 



• Testicular epididymal sperm aspiration (TESA) — 
sperm are retrieved using an open testicular biopsy 
technique 

• In vitro fertilization (IVF) — eggs are retrieved from the 
ovary and fertilized by the man's sperm in the lab; sev- 
eral days later, a number of fertilized embryos are 
transferred into the uterus; the remaining embryos can 
be cryopreserved for use in subsequent cycles 

• Assisted hatching — micromanipulation of the embryo 
to increase implantation success 

• Egg donation — women whose ovaries have been 
removed, or do not function normally, can receive 
donated eggs from another woman; these eggs are 
fertilized by the husband's sperm in the lab and later 
implanted into the uterus 

• Gestational surrogacy — transferring the embryo into 
another woman who carries the pregnancy to term 

• Traditional surrogacy — artificially inseminating a 
woman who carries a baby to term; the baby will then 
be raised by its genetic father and his partner 

• Embryo cryopreservation — freezing and storage of 
embryos in liquid nitrogen 

• Hysteroscopy with tubal cannulization — visual exam- 
ination of the interior of the uterus to check for abnor- 
malities 

• Laparoscopy — procedures using a fiber-optic scope 
passed into the abdomen through a tiny incision below 
the navel 

• Psychological services 



Regulatory Issues 

Although IVF is not specifically defined in the codes, the 
facility can be viewed as having three basic components 
that are well defined in various codes and can be relied 
on to guide decisions. These are the examination/medical 



132 Medicine: Specialized Suites 



office component, which, in most codes, is a business 
occupancy (assuming this is not a hospital-based facility); 
the clinical laboratory; and the operating room suite. One 
should consult the state's business and professions code, 
if such exists, as well as the state's department of health 
services. There are nationally recognized accreditation 
agencies such as AAAHC and AAAASF (refer to the 
Plastic Surgery section and Chapter 7 for detailed dis- 
cussion of these agencies) that will accredit these facili- 
ties, and there is JCAHO, but practitioners may also wish 
to consider state accreditation agencies for ambulatory 
care. As an example, in California, it's the Institute for 
Medical Quality, a subsidiary of the California Medical 
Association. This agency is approved by the Medical 
Board of California to verify compliance with assembly bill 
AB-595, also known as the Spiers Bill. Similar bills may 
have been enacted in other states, but in California, as of 
1996, any medical practice from solo to small group to 
multiservice ambulatory centers that administers general 
anesthesia must be either licensed by the Department of 
Health Services, obtain Medicare certification, or be 
accredited. 

Clearly, licensing and Medicare certification are quite 
rigorous in terms of facility design, whereas many accred- 
itation agencies focus more on policies and procedures 
such as infection control measures, patients' rights, hospi- 
tal transfer agreements, quality management/quality 
improvement, calibration logs of equipment, documenta- 
tion of periodic safety drills, testing of back-up power, 
pharmaceutical control logs, and review of medical charts. 
Achieving Medicare certification will most likely mean that 
the surgery center portion of the suite — even if it's just 
one procedure room with ancillary spaces — will be isolat- 
ed from the medical office, having its own entry, business 
office, and waiting area. This is what is demanded for 
office-based surgery facilities. However, it is clearly a gray 
area for IVF suites because the nature of what is done in 
the procedure room is "procedures" rather than surgery. 

General Anesthesia Is the Trigger 

If general anesthesia is used, the facility will have to be 
licensed or accredited. The AIA Guidelines for Design 



and Construction of Hospital and Healthcare Facilities 
should be used as a guide, along with NFPA 101 Life 
Safety Code. Many physicians do not use general anes- 
thesia for these procedures and, instead, use monitored 
anesthesia care (IV sedation with oxygen), which causes 
a twilight sleep and does not involve intubation. An anes- 
thesiologist would participate during these procedures 
and resuscitation equipment should be available in the 
procedure room. 

Clinical Lab Regulatory Issues 
Certification. Certification is both mandatory and vol- 
untary for the clinical lab component of the suite, which 
involves blood draw, the andrology lab, and the 
IVF/embryology lab. Currently, three states — California, 
New York, and Florida — require clinics to be licensed as 
a tissue bank if human tissue is collected, processed, 
stored, or distributed for purposes of transplantation in 
either the andrology or the embryology lab. States also 
issue licenses for clinical laboratories and one would 
have to be certified by CLIA (Clinical Laboratory 
Improvement Act), a federal program regulated by the 
Health Care Financing Administration (HCFA). The 
reader is referred to a discussion of CLIA in Chapters 3 
and 5. 

On July 21, 1999, the Department of Health and 
Human Services released to state officials and health 
authorities a model certification program developed by 
the Centers for Disease Control and Prevention (CDC) 
encouraging the adoption of this program by individual 
states. It contained a set of quality standards that states 
could use for inspecting and certifying laboratories used 
in fertility clinics that provide assisted reproductive tech- 
nology. However, certification of these laboratories by 
states is voluntary. 

Accreditation. For physicians to become members of the 
Society of Assisted Reproductive Technology (SART), the 
andrology and embryology laboratories must pass a 
national laboratory accreditation inspection program for 
reproductive laboratories developed by the College of 
American Pathologists (CAP) and the American Society 



Reproductive Enhancement (Assisted Reproductive Technologies) 133 



for Reproductive Medicine (ASRM). Using a checklist, the 
CAP/ASRM Reproductive Laboratory Accreditation 
Program examines all aspects of quality assurance in the 
laboratory, including methodology, reagents, control 
media, equipment, specimen handling, procedure manu- 
als, reports and proficiency testing, qualifications of per- 
sonnel, safety, and the overall management policies that 
distinguish a quality laboratory. Upon successful comple- 
tion of the inspection process, the laboratory will be 
awarded CAP accreditation. In some states, CAP accred- 
itation satisfies the state's regulatory agency. 

Reimbursement. Since most third-party payers do not 
reimburse for assisted reproductive technologies, achiev- 
ing Medicare certification to be able to bill a facility fee 
becomes a moot point. 



Process and Patient Flow 



IVF lab acts as a temporary womb to support fragile 
gametes (eggs and sperm) and nurtures newly formed 
embryos until they are transferred to the uterus; there- 
fore, the environment has to be very carefully controlled. 

Sperm Collection 

The collection room, sometimes referred to euphemisti- 
cally as the donor room, is where sperm are collected. 
This room should be furnished like a comfortable lounge, 
with a TV and VCR. The pressure on a man to perform is 
enormous. A man may ejaculate through masturbation or 
with the help of a partner in the room. Although there are 
many steps involved, a simple explanation is that sperm 
are first separated from the seminal fluid through repeat- 
ed washing and spinning in a centrifuge, later to be sub- 
jected to capacitation (alterations to the surface of the 
sperm head accomplished by incubating it in a specially 
prepared culture to increase its ability to penetrate the 
egg). 



The initial visit starts with a comprehensive physical and 
gynecological exam, a review of family and social histo- 
ry, and a review of male-related infertility issues. This ini- 
tial interview and examination may take 45 to 50 min- 
utes. Because the reasons for infertility problems are so 
diverse, the number of procedures to address these 
problems are similarly diverse. To give some idea of what 
is involved, consider two of the most frequent proce- 
dures, egg retrieval and egg transfer. In addition to tak- 
ing hormones, the woman will take a medication at home 
and within a specified period of time — generally 35 
hours — must come to the office for the egg retrieval. 
This is an ultrasound-guided needle aspiration proce- 
dure that is typically done under conscious sedation. 
Patients are understandably very nervous prior to this 
procedure. Afterward, the patient is transferred on a gur- 
ney to the recovery room where she remains for approx- 
imately an hour. Eggs and embryos are kept inside an 
incubator while in the embryology lab except when they 
are removed to be inseminated, changed to a new cul- 
ture medium, or prepared for transfer to the uterus. The 



Micromanipulation 

During the process of micromanipulation, which uses a 
specialized inverted microscope, sperm are introduced 
into the egg by the embryologist. About 16 to 20 hours 
after insemination, the embryologist transfers each egg to 
a new growth medium to enhance its development and 
encourage cell division if fertilization has occurred. 

Embryo Transfer 

Finally, an ultrasound-guided embryo transfer to the 
uterus is performed. It's important that the woman be as 
relaxed as possible during embryo transfer as many 
stress-related hormones such as adrenalin can cause 
the uterus to contract. The nurse coordinator or coun- 
selor often sits at the bedside to coach the patient in 
relaxation techniques, often using guided imagery. 
Following the procedure, the patient is usually asked to 
lie on her back or side for one to two hours in the recov- 
ery area. This is a delicate procedure and it's important 
that no bleeding occurs and that the embryos are not 
damaged. 



134 Medicine: Specialized Suites 



Schedule of Visits 

Patients make frequent visits, which often involve blood 
draw and ultrasound examinations. Patients are often 
asked to drink a great deal of water prior to an ultrasound 
examination; therefore, a bathroom should open off the 
examination room (Figure 4-32) or immediately adjacent. 
The initial interview usually takes place in the physician's 
office or consultation room, followed by a discussion with 
the financial counselor. There are quite a number of 
sequential visits that need to be scheduled. Often, a close 
bond forms between the patient and the nurse coordinator 
who, over time, offers reassurance, support, and guidance. 



Clinic Components 

The program in Table 4-2 is based on an embryology lab 
equipped to process 300 to 600 retrievals per year. The 
space plans in Figures 4-32, 4-33, and 4-34 represent, 
respectively, a one-physician practice, a three-physician 
practice, and a four-physician practice. It should be noted 
that IVF procedure rooms are clean rooms, but not sterile. 
A number of procedures can be done in a smaller "minor" 
procedure room. These rooms should not have sinks as 
they compromise infection control. 

Critical Adjacencies 

Embryology/IVF Laboratory. Ideally, as exemplified by 
Figures 4-32, 4-33, and 4-34, the IVF lab is contiguous 
with the procedure rooms. If the distance to the place of 
egg retrieval or embryo transfer (the procedure room) 
exceeds 100 feet, then the use of an infant isolette or 
other method of maintaining temperature and pH for the 
eggs and embryos must be employed. Intercom commu- 
nication is recommended if direct communication is not 
possible. The laboratory should be in a low-traffic, 
secured area with access limited to the embryologist and 
techs who work in the lab. Security is of utmost impor- 
tance to maintain the sterile conditions of the space as 
well as to protect the specimens. 



Table 4-2. 

Analysis of Program. Advanced 

Reproductive Technologies 



Business/Administration 

Waiting Room 

Reception 

Business Office 3 

Conference Room 

Staff Lounge 

Staff Toilets 

Storage 

Office Manager 

Financial Counselor 

Donor Program Coordinator 

Lab Director 

OR Nurse 

IVF Coordinator 

Psychologist 

Resource Library/Patient Education 
Clinical Areas 

Exam Rooms 

Nurse Stations 

Blood Draw 

Collection Room 

Toilets 

Consultation Rooms 
Andrology Lab 
Embryology Lab 

Micromanipulation Area 

Cryopreservation Prep and Storage 

Male/Female Gowning/Lockers 

Storage (Med Gases and Supplies) 
Procedures/Operating Suite 

OR 

Procedure Room 

Scrub 

Clean Utility 

Soiled Utility 

Central Supply 

Recovery Areas 

Janitor Closet 

Miscellaneous 6 

Subtotal 

20% Circulation 

Total 



20 X 20 


= 


400 


— 




180 


— 




550 


— 




300 


12 X 12 


= 


144 


7X8 


= 


112 


8 X 10 


= 


80 


10 X 12 


= 


120 


10 X 12 


= 


120 


8 X 10 


= 


80 


10 X 12 


= 


120 


8 X 10 


= 


80 


8 x 10 


= 


80 


10 x 12 


= 


120 


10 X 12 


= 


120 


10 x 10 


= 


600 


8 x 12 


= 


192 


6X8 


= 


48 


10 x 10 


= 


100 


7X8 


= 


168 


12 X 12 


= 


432 


10 X 12 


= 


120 


— 




720 



20 X 20 


= 400 


14 X 16 


= 224 


— 


24 


8 x 10 


= 80 


8 x 10 


= 80 


10 x 10 


= 100 


8 x 10 


= 160 


4X6 


= 24 


— 


80 




6158ft 2 




1232 




7390 ft 2 



"Includes medical records, billing, and workroom (mail/copy). 
6 Biohazardous storage, medical gas storage, vacuum, and generator. 
Note: This program supports three physicians. 



Reproductive Enhancement (Assisted Reproductive Technologies) 135 




1 


WAITING ROOM 


2 


RECEPTION 


3 


FINANCIAL COUNSELING 


4 


OFFICE MANAGER 


5 


ENDOCRINOLOGY 


6 


LAB DIRECTOR 


7 


EXAM / PROCEDURE 


8 


TOILET 


9 


CONSULTATION ROOM 


10 


RECOVERY 


11 


NURSES' STATION 


12 


SCRUB 


13 


MINOR PROCEDURE ROOM 


14 


IVF LAB 


15 


ANDROLOGY LAB 


16 


CLEAN UTILITY 


17 


SOILED UTILITY 


18 


HAZARDOUS WASTE 


19 


JANITOR 


20 


DONOR COLLECTION 


21 


UPS / GAS / TELEPHONE 



SMOTRICH CENTER FOR REPRODUCT IVE ENHANCEMENT 

3414 SF 

Figure 4-32. Space plan, 341 4 square feet. Smotrich Center for Reproductive Enhancement, La Jolla, CA. (Design: Jain Malkin Inc.) 



136 Medicine: Specialized Suites 




REPRODUCTIVE MEDICINE 

7344 SF 
Figure 4-33. Space plan for reproductive medicine, 7344 square feet. (Design: Jain Malkin Inc.) 



Andrology Lab. This is not a clean room (although ster- 
ile technique is used) and it need not be adjacent to the 
IVF lab. Semen analysis is done here as well as sperm 
capacitation and cryopreservation. 

Media Prep Room. Various culture media are prepared 
in this room. It can be within the IVF lab or adjacent 
to it. 

Collection Room. This is best located in a quiet area of 
the suite and should be reasonably close to the androlo- 
gy lab where semen is analyzed and sperm undergo the 
capacitation process. In fact, in some facilities (Figures 



4-32 and 4-33) the collection room is adjacent to the 
andrology lab and there is a pass-through between the 
two rooms. However, it has an interlock that prevents 
someone in the lab from looking into the collection room. 

Laboratory Equipment 

Most of the equipment in the andrology and embryology 
laboratories is highly specialized for use in ART labs. The 
pieces of equipment are too numerous to be able to 
include photos in this chapter. Instead, following are the 
names of respected vendors for the larger pieces of 
equipment. Each has a Web site featuring equipment 
options and specifications. 



Reproductive Enhancement (Assisted Reproductive Technologies) 137 



Figure 4-34. Space plan, 18,000 
square feet. In vitro fertilization clinic. 
{Planning and interior design: 
Perkins & Will, New York, NY.) 





THE CENTER FOR HUMAN REPRODUCTION 

18,000 S.F. 



Heraeus (incubators) 

Forma Scientific, Inc. (incubators, cryopreservation dry 
shippers, laminar-flow bench workstations) 

MVE (liquid nitrogen freezers) 

Nikon (inverted microscope) (Note: a video camera 
may be used with this.) 

Eppendorf (micromanipulator, centrifuges) 

Mid-Atlantic Diagnostics: K-System (air suspension 
workbench with stereo microscope built into a vertical 
laminar flow cabinet) 



Barnstead/Thermolyne (test tube mixers, rotators, and 
shakers) 

Thermo Forma (microcentrifuges) 

Diagnostics Products Corporation (Immulite endocrine 
analyzer) 

A list of the principal pieces of equipment follows. It 
should be noted that there are consultants specific to the 
IVF field who specify equipment and do the laboratory 
layout, although the embryologist will have considerable 
input and may, in fact, take entire responsibility for the 



138 Medicine: Specialized Suites 



design and equipment selection (Figure 4-35). The rela- 
tionship of each piece of equipment to another affects the 
electrical plan, requiring careful coordination. 

General Lab Equipment. Includes refrigerators and 
freezers; cryogenic storage tanks; specialized micro- 
scopes; air suspension tables; centrifuges; test tube 
mixers, shakers, and rotators. 

Andrology Lab. Includes laminar-flow hood; refrigera- 
tor; centrifuges, both large and small; phase micro- 
scope with fluorescence; warming oven; water-jacket- 
ed C0 2 incubator; dry shipper tanks (Figure 4-35). 

Embryology Lab. Includes laminar-flow hood; stereo 
microscopes; stage warmers; centrifuges, large and 
small; computers and printer; incubators (tabletop 
model, water-jacketed C0 2 , and high-effieciency partic- 
ulate air [HEPA]-filtered C0 2 ); water purification system; 
waterline pressure pump and tank; dry heat ovens. 

Embryology Micromanipulation Area. Includes air sus- 
pension table (to minimize vibration); inverted micro- 
scope; video camera, monitor, and recorder; stage 
warmer. The video camera and monitor enable the 
embryologist to perform the procedure at magnification 
on the monitor, rather than looking through the micro- 
scope. It also shows (if the OR has a large monitor) the 
embryo being loaded into the syringe just prior to the 
transfer procedure. 

Cryopreservation Area. Includes laminar-flow hood, 
planar cell freezer, heat sealer, stereo dissecting 
microscope, liquid nitrogen tanks. 

Microscopes need to be at sit-down workstations and 
must be at a comfortable height for the embryologist. This 
can differ depending on whether that individual is short or 
tall, which can sometimes be accommodated by adjusting 
the chair height. The selection of a task chair for this posi- 
tion is also very important as individual comfort and 
ergonomic features matter. 



Note that there should not be overhead cabinets above 
the balance table in the micromanipulation area, the com- 
puterized semen analyzer, the cryopreservation counters, 
or the autoclave area. Areas under the cryopreservation 
countertop should be open to accommodate liquid nitro- 
gen storage tanks on wheels. C0 2 lines should be cen- 
trally piped to the workbenches where it is needed. The 
endocrine analyzer can, if space is limited, be located 
outside the lab. 

Lab Storage. If an adequate water purification system is 
not centrally installed, there will be a need to store quan- 
tities of ultra-pure water, which is delivered in large bot- 
tles. There are also many chemicals that need to be 
stored to support the lab functions. 

Utility Requirements 

HVAC/Air Quality Standards. Air quality is an important 
factor when trying to maintain process integrity. Testing 
reliability, results, and personal protection can be affect- 
ed by airborne contamination. Air quality in laboratories 
is defined by Federal Standard 209E with classifications 
of Class 1 , 1 0, 1 00, 1 000, and so on. This Class number 
is the maximum allowable number of particles 0.5 micron 
and larger per cubic foot of air; the lower the number, the 
cleaner the air. International Standard IS01 4644-1 clas- 
sifications are rated as ISO Class 1 , ISO Class 2, and so 
forth. According to both standards, Class 1 is the clean- 
est, ultra-pure air. ISO Class 2 correlates most closely to 
Federal Standard Class 1 00. The standard for an embry- 
ology lab is Class 100 air quality. The labs will have sev- 
eral laminar-flow hoods for carrying out certain proce- 
dures. The room should have a four-stage HE PA filtration 
system that purifies the air of the entire lab. The labs must 
have individual temperature, humidity, and velocity con- 
trols and there must be access to overhead ducts for 
periodic cleaning and changing of air filters. Air intake 
must not be near any source of contaminiation, and air 
from the hoods may need to be ducted directly to the out- 
doors, due to the chemicals used. 



Reproductive Enhancement (Assisted Reproductive Technologies) 139 




Figure 4-35. Layout, embryology and andrology labs. {Planning: Jain Malkin Inc.) 



140 Medicine: Specialized Suites 



Lighting. Lighting in each section of the lab should be 
individually dimmable. It must be an incandescent source 
as fluorescents generate a frequency that may affect cel- 
lular development of the embryos. Procedures in exam 
rooms are generally done in full light, but being able to dim 
the lights during ultrasound is advisable. This could also 
be accomplished by being able to turn off the overhead 
lights and have just a wall sconce remain (Color Plate 14, 
Figure 4-36). In large procedure rooms, a ceiling-mounted 
surgical light is required. Here, as well, being able to dim 
the lights is important during ultrasound-guided proce- 
dures. There will be a large video monitor placed so that 
the patient can see when the embryologist loads the 
syringe for the embryo transfer. Room lighting needs to be 
placed to avoid glare on monitors. 

Electrical. Of utmost importance in the labs is an unin- 
terrupted power source for incubators, alarm systems, 
and monitors. Various types of back-up power systems 
are available. In addition, surge protection is needed for 
all electrical and electronic equipment. 

Security and Alarm Systems. Laboratory security some- 
times involves video cameras. Depending on the number 
of people who have access to the lab, a fingerprint identi- 
fication system or magnetic card reader may be required. 
Alarm systems monitor incubators, gas and liquid nitrogen 
tanks, and cryotank monitors, relaying a message when 
equipment malfunctions. Successful results in this spe- 
cialty demand precise temperature control and environ- 
mental conditions. Forma Scientific makes a 
monitor/alarm system that can interface with up to 24 
pieces of equipment. It also makes the Sensaphone® tele- 
phone dialing system that interfaces with the alarm system 
to automatically dial several sequential telephone num- 
bers of laboratory staff if something is amiss at the lab. 

Medical Gases. There are a large number of medical gas 
cylinders within this suite. Even if general anesthesia is 
not used, there will be a need for centrally piped oxygen 
in the procedure rooms and the recovery room. The IVF 
culture area and micromanipulation area require vacuum 



and C0 2 . The cryopreservation area requires liquid nitro- 
gen (LN 2 ) and vacuum, and the media prep and androlo- 
gy areas require C0 2 and vacuum. 

Plumbing. Sinks must be precisely located in the labora- 
tory areas. In addition, certain pieces of equipment may 
need to be connected to water and drain. As in any lab, 
noncorrosive piping must be used and sinks should be 
stainless steel. Eyewash diverters on sinks must meet 
OSHA requirements. 

Interior Design Considerations 
Embryology Laboratory. Purity of materials is of utmost 
importance. Off-gasing of volatile organic compounds 
(VOCs) from synthetic materials and contact cements 
used in plastic laminate casework should be reduced to 
the minimum possible. At completion of construction, 
high-velocity air filtration and fans should be used to 
exhaust as much of the construction dust and off-gasing 
of materials as possible prior to commissioning the lab. 
Usually, for two weeks prior to using human specimens, 
mouse or hamster eggs may be used to test conditions. 
Walls and floors should have no seams or crevices to 
reduce the possibility of contamination and make clean- 
ing easier. Sheet flooring such as linoleum (made with 
natural materials) can be self-coved at the base to elimi- 
nate crevices. In terms of color, labs should be fairly neu- 
tral but white creates too much glare. A beige floor and 
walls work well. Embryologists often prefer to work on 
dark-colored (charcoal) countertops because it makes it 
easier to see dust. The doors to laboratories must have a 
sign saying Authorized Staff Only. 

Procedure Room. Physicians often prefer a medium to 
dark floor in these rooms to eliminate glare. Note that the 
door will require a sign Proper Surgical Attire Required. 



Accommodation of Celebrities 

Well-established ART practices often attract celebrities, 
foreign dignitaries, and even heads of state who will be 



Reproductive Enhancement (Assisted Reproductive Technologies) 141 



ushered into the office through a private entry, bypassing 
the waiting room. Occasionally, to accommodate these 
individuals, the office is closed so that no one but staff is 
present during the visit. 



Relevant Art 

A collection of fertility dolls from various cultures is inter- 
esting and relevant. Although not recommended for the 
waiting room, in a corridor, a large photo wall can be 
attractively created with photos of parents and their 
babies. Physicians in this specialty receive hundreds of 
photos from grateful patients. These range from poorly 
composed snapshots taken with disposable cameras to 
professionally posed photos with twins or triplets wearing 
matching outfits with a seasonal theme such as Easter 
bunnies or valentines. They are fetchingly adorable. Most 
photos will be color, which will make the overall effect 
quite busy. A solution is to take all of them to a profes- 
sional photo lab and have an internegative made to con- 
vert them to crisp black-and-white prints, in exactly the 
desired sizes to fit the designer's selection of frames. 
Additionally, magazine and newspaper articles featuring 
the physician(s) can be attractively matted and profes- 
sionally framed. The physician's diplomas should be 
prominently displayed in his or her consultation room (pri- 
vate office). Frames need not match and are more inter- 
esting if they complement each other, but don't match. 
This is not the time to go to Aaron Brothers to buy a pic- 
ture frame. Patients need to have confidence in the fertil- 
ity specialist since they are investing a great deal of time, 
emotion, and money in this endeavor. 



by chemotherapy and/or radiation therapy. This discussion 
will focus on medical oncology, not radiation therapy. [The 
author's other book, Hospital Interior Architecture, also 
published by John Wiley, has an extensive chapter on radi- 
ation oncology facilities; however, several photos of linear 
accelerator installations are included in Chapter 5.] 

The oncologist manages the patient's cancer treat- 
ments, conferring from time to time with the primary-care 
physician or specialist who referred the patient. Many 
medical oncologists prefer to do chemotherapy infusion in 
their offices rather than refer the patient to the hospital. 
This offers convenience for patients and a feeling of secu- 
rity that they are being treated under the watchful eye of 
their oncologist. The initial visit will typically be lengthy — 
perhaps an hour — and will occur in the oncologist's con- 
sultation room (private office). A view box illuminator or 
monitor for reading digital X-rays is required. These prac- 
tices may include one or two physicians, or they may con- 
sist of a large group of 10 or 12 oncologists who are the 
prominent group providing major cancer care at the hos- 
pital on the MOB campus. Surgeons may become well 
known for certain types of surgical techniques, attracting 
patients from considerable distances. As an example, the 
suite plan in Figure 4-37 was designed for a gynecologi- 
cal oncologist. 

The large cancer center in Figure 4-38 represents an 
unusually good functional layout of rooms, maintains 
appropriate critical adjacencies, and also has aesthetic 
flair with numerous curves, ceiling treatments, and design 
details. 



Patient Flow 



ONCOLOGY 

Oncologists treat cancer. Patients are referred by their pri- 
mary-care physician or a specialist such as a urologist, 
gynecologist, gastroenterologist, or dermatologist, to 
name a few. Once a tumor or lesion has been identified, 
surgery is usually the first form of treatment, often followed 



A course of chemo infusion may require visits once or 
twice a month for six months for certain regimens, or 
three days per week once a month, or two visits per 
month. The average infusion time is four hours, which 
means that patients get to know each other and provide 
encouragement and support to each other. Patients often 
arrive with a close friend or family member for company, 
necessitating a guest chair. 



142 Medicine: Specialized Suites 



73-0" 




ONCOLOGY 



Figure 4-37. Space plan for oncolo- 
gy, 2644 square feet. Note: 
Chemotherapy drugs are not pre- 
pared in this suite; they are deliv- 
ered daily. (Design: Jain Malkin Inc.) 



2644 SF 



Patients first go to an exam room 75 percent of the time to 
see a doctor or nurse practitioner to reassess their situation 
and find out how they've been doing. Next, blood is drawn to 
verify that the white count is high enough to receive the next 
dose of chemo. Some practitioners draw blood in the exam 
room, while others use a blood draw chair in the lab. Still oth- 
ers do it in the recliner chair of the infusion bay as the IV is 
put in so that blood can be drawn for the CBC (complete 
blood count) so that the patient doesn't have to be stuck 



twice with a needle. A countertop CBC analyzer located in 
the lab provides results in 90 seconds. 

Although in most facilities it is assumed that patients 
will be tethered to a recliner chair and not walk around 
during infusion, if the patient is feeling well, there is no 
reason why he or she cannot work a puzzle at a table or 
sit in a living room setting socializing with friends. 

Many patients who visit oncologists do not receive 
chemotherapy. These patients may be on medications 



Oncology 143 



Figure 4-38. Space plan, 18,260 square feet. Saint 
Jude Medical Center Cancer Center. {Planning: 
Haynes and Oakley Architects, Sierra Madre, CA 




144 Medicine: Specialized Suites 



that need to be monitored from time to time. For example, 
a patient with a slow-growth prostate cancer who is on 
medication to reduce the growth of the tumor will require 
frequent PSA (prostate-specific antigen) tests to monitor 
progress. In this practice, there are many return visits and 
a great deal of rapport and camaraderie often develops 
between the patients and staff over the years. 



Space-Planning Considerations 



Nurse Station 

The nurse station should be at the front of the suite, con- 
venient to exam rooms. Registered nurses, nurse practi- 
tioners, and/or medical assistants may work out of this 
room. The room will require a scale and may have a 
Pyxis™ Omnicell™ unit for dispensing and charging med- 
ications (Figure 4-39), a desk-height workstation with 
telephone and computer, ample storage for supplies, and 
a handwash sink. A full-height refrigerator is needed if a 
refrigerated medication dispensing unit like Pyxis or 
Omnicell is not used. 

Laboratory 

This is the most complex room in the suite and is often 
poorly designed, from a functional standpoint, because of 
the designer's lack of understanding of the numerous 
pieces of equipment that must be accommodated or, as 
is often the case, the space available falls far short of 
what is required for this room. This can result in printers 
tucked under countertops (Figures 4-40 and 4-41), com- 
puter keyboards placed in awkward locations (Figure 
4-42), and pieces of equipment that should be placed 
side by side (Figures 4-43 and 4-44) tethered to each 
other by cords running along a wall. 

Typically, the R.N. who mixes the chemicals also admin- 
isters them to the patient. Because chemo drugs are high- 
ly toxic, this room is kept locked so that janitorial staff do 
not have access to it. Some oncologists have installed 
machines like Pyxis that keep an inventory of drugs, help 
to prevent error in dispensing medication, and provide 




Figure 4-39. Nurse station, oncology suite. (Photographer: Jain Malkin.) 



greater assurance that patients will be charged for all the 
meds. The Pyxis or Omnicell system automatically inter- 
acts with the billing system and charges the patient's 
account, as drugs are dispensed, and then also automat- 
ically reorders. There could be three or four drugs dis- 
pensed in one chemo preparation. Other meds like flu vac- 
cines would be kept refrigerated at the nurse station. 



Oncology 145 





Figure 4-40. Nurse station and lab, oncology suite. {Photographer: 
Jain Malkin.) 



Figure 4-41. Nurse station and lab, oncology suite (continuation of 
Figure 4-40). (Photographer: Jain Malkin.) 



Integration of Equipment. The large piece of equipment 
in Figure 4-42 is a blood count analyzer. This unit is close 
to the sink because it has a drain line that empties into 
the sink. It is an example of how, when adding new pieces 
of technology, in an effort to save money the physician 
may not want to make a hole in the cabinet to enable the 
drain line to connect to the plumbing under the sink. Over 
time, with a number of machines added, the room 



becomes cluttered with jury-rigged connections. The lab 
in Figures 4-40, 4-41, 4-43, and 4-44 has several printers 
that would ideally be stacked in a vertical column with 
adjustable shelves, as indicated in the space plan layout 
shown in Figure 4-45. The blood count analyzer has a 
printer, as does the Pyxis, and there is a printer connect- 
ed to the medical management software that prints 
labels, and another printer directly connected to a refer- 



146 Medicine: Specialized Suites 




Figure 4-42. Laboratory, oncology suite. Note clinical analyzer on countertop. {Photographer: Jain Malkin.) 

ence lab. A room 10X16 feet would be ideal. There also 
needs to be a kneespace workstation with telephone and 
computer monitor. If an automated medication dispensing 
unit is not used, a refrigerator for chemicals will be 
required. There will also be a centrifuge on the countertop 
as blood specimens that are sent out need to be spun 
down first. Generally, only blood counts are done in the 
office; all other lab work is sent out. 

Biological Safety Cabinet. Chemotherapy infusion 
chemicals are mixed in a biological safety cabinet 
(Figures 4-43 and 4-46), which is a unit that protects the 
nurse or tech. It has laminar flow and a HEPA filter and 
generally need not be vented to the outside. The nurse 
must wear gloves, mask, gown, and safety goggles for 




Figure 4-43. Laboratory, used for chemotherapy drug preparation (oppo- 
site side of room depicted in Figure 4-42). Note biological safety cabinet 
and, to the right, refrigerated medication inventory and dispensing unit. 
{Photographer: Jain Malkin.) 



Oncology 147 




Figure 4-44. Chemotherapy laboratory, oncology suite (wall opposite 
that depicted in Figure 4-43). Note that the tall cabinet is a refrigerated 
medication inventory and dispensing unit. {Photographer: Jain Malkin.) 




ENTRY 



ONCOLOGY 



3146 SF 
Figure 4-45. Space plan for oncology, 3146 square feet. (Design: Jain Malkin Inc.) 



148 Medicine: Specialized Suites 



mixing of chemicals, but only the gown and fresh gloves 
are worn when the chemicals are administered to the 
patient. The cabinet by Forma Scientific is called Class II 
Type A or AB, which refers to ventilated cabinets with 
open fronts that use inward airflow for personnel protec- 
tion, have HEPA-filtered laminar airflow for product pro- 
tection, and have HEPA-filtered exhausted air for environ- 
mental protection per NSF (National Science Foundation) 
Standard 49. Biological safety cabinets are the primary 
containment devices used in laboratories to prevent the 
escape of aerosols. As an optional feature, the cabinet 
can be vented to exhaust to the outdoors. Local codes 
must always be consulted in these matters. 

Utility Requirements. The benchtop model includes a 
built-in drain valve, a service valve, and one plugged 
penetration. The unit incorporates two separate circuit 
breakers and two line cords, one for the blower/motor and 
interior lights and one for the electrical outlet. 

Patient Visibility 

A nurse station is always adjacent to the chemo infusion 
area so that patients are constantly observed. In addition, 
nurses are continually circulating through the infusion 
area to change bags of chemicals on the IV stands as 
they are emptied. If the lab is contiguous with the infusion 
area, there is often a window through which one could 
observe patients. The lab should be as close to the infu- 
sion area as possible so that nurses always maintain con- 
tact with patients and chemicals do not need to be carried 
throughout the suite. 




OSHA 

OSHA has many requirements for biohazardous waste 
and protection of workers, more fully discussed in 
Chapter 3. Among these are an eyewash device at the 
sink in the lab. The closet for biohazardous waste needs 
to be locked and should ideally be located near the serv- 
ice or staff entrance to the suite for easy collection by a 
contracted vendor. 

OSHA's Office of Occupational Medicine, in a report 
titled "Exposure to Hazardous Drugs," describes antineo- 



Figure 4-46. Biological safety cabinet used for preparation of 
chemotherapy drugs. (Photographer: Jain Malkin.) 



Oncology 149 




Figure 4-47. Chemotherapy infusion lounge. (Photographer: Jain Malkin.) 



plastic drugs (cytochemotherapeutic agents) as agents 
capable of inhibiting tumor growth by disrupting cell divi- 
sion and killing actively growing cells. The potential haz- 
ards for oncology nurses who prepare the chemicals are 
substantial unless very strict protocols are followed. The 
exposure occurs by inhalation of the aerosolized drug 
(thought to be the primary exposure route), percutaneous 
(through the skin) absorption, and accidental ingestion. 
All surfaces of the room should be easy to clean, with 
few crevices or seams. A high-quality sheet vinyl with 
self-coved base is ideal. An additional issue is the laun- 
dering of linen or uniforms that have been contaminated 
with chemotherapeutic drugs or infectious agents. 



Universal precautions must be followed for this laundry. 
However, cytotoxic drugs (chemicals that are directly 
toxic to cells, preventing their reproduction or growth) are 
not necessarily rendered harmless by laundering, 
according to OSHA, and should be prewashed to remove 
as much of the drugs as possible before coming into con- 
tact with other laundry. Proper storage of contaminated 
linen should be provided so that housekeeping personnel 
do not risk exposure. 

Off-Site Preparation of Chemotherapy Drugs 

Some oncologists do not prepare chemotherapy drugs in 
their offices. They are prepared off site at the hospital 
pharmacy or delivered by a pharmaceutical supply ven- 
dor. In this case, there may not be a lab or the lab will be 
quite minimal as in Figure 4-37 where, in addition, patients 
are sent to the lab in the building for their blood tests. 

Chemotherapy Infusion 

Although spaces designed for this function are often 
nothing more than a large room with a group of recliner 
chairs, often placed too closely together, gregarious indi- 
viduals welcome the closeness and conviviality such a 
setting often fosters (Figure 4-47). According to 
research, providing options and choices reduces stress. 
The environment in Figure 4-48 offers more space for 
each chair; includes individual sloped magazine racks, 
CD players, and VCRs; has views of nature and access 
to natural light (if the patient were to turn and look out the 
window); maintains good visual contact with the nurse 
station; and displays variety in lighting. The chair has 
speakers built into the back at shoulder level and "thera- 
peutic" music. The space plan for this infusion unit is pre- 
sented in Figure 4-38. 

Other Planning Considerations 

Personal Space. Provide a place for personal belongings 
such as briefcases, books, or handbags so that they are 
not on the floor where the nurse might trip on them. The 
casework in Figure 4-49 between every two chairs pro- 
vides a measure of privacy, a place to attach the bracket 



150 Medicine: Specialized Suites 



for a personal TV, and the end of the cabinet lifts up for 
access to commonly used supplies needed by nurses. 

Nonclinical Appearance. A wood-look sheet vinyl floor 
adds warmth to the room. There are no restrictions 
against plants or carpet if a living room option is provided 
with a puzzle table and lounge chairs. Locating the infu- 
sion area on an upper floor (if there is an option) some- 
times conveys the feeling of being in a treehouse as in 
Figure 4-49. Research shows that connecting patients to 
nature by way of views, water elements, or even simulat- 
ed views of nature greatly reduces stress. 

Patient Safety. Allowing adequate space around each 
chair is necessary to assure patient safety. In a "code" sit- 
uation, staff must have ready access to all sides of the 
patient, especially the head. 

Visibility. Patients typically want to know that they can be 
seen by the nurse and they often find it diverting to watch 
the activity at the nurse station. There is always the trade- 
off (especially when a beautiful view is available outside 
the windows) of turning the chairs so that they face the 
view, which means that they generally no longer face the 
nurse station. 

Waste Receptacles. It is hard to imagine how much 
waste is generated in an infusion setting unless one 
observes the activity for several hours. Infusions are 
packed in thick plastic pouches hanging on IV stands. The 
idea is to enable the nurse to discard the empty bag with- 
out having to walk very far to do it. The same is true for 
sharps containers, yet one wouldn't want to see them 
exposed next to the patient. The shorter the distance one 
has to walk to dispose of sharps or chemo bags the less 
opportunity there is for exposure or needle sticks. It takes 
a very thoughtful designer to address these functional 
issues so that these items are built in and unobtrusive. In 
addition, there are numerous large waste carts on cast- 
ers that are unattractive to look at and rarely are they well 
accommodated by the designer. 




Figure 4-48. Chemotherapy infusion provides options for privacy and many amenities for patients. Saint 
Jude Medical Center Cancer Center. (Architecture and interior design: Haynes and Oakley Architects, 
Sierra Madre, CA; Photographer: Barbara White Architectural Photography.)\ 



Oncology 151 




Figure 4-49. Chemotherapy infusion in a treetop setting. {Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Hand Washing. Locate sinks in several locations to make 
it convenient for nurses and doctors to wash their hands. 
This is essential for infection control. 

Other Amenities. A restroom must be nearby, along 
with a place for self-serve beverages. Family and 
friends must be accommodated as most patients seem 
to arrive with another individual for emotional support. 
Pleasant diversions such as a saltwater aquarium, an 



interactive work of art, a library of videotapes, and a 
table with a jigsaw puzzle are welcome diversions. 
Think about a humor corner with decor and resources 
all focused on laughter and mirth. The 7000-square-foot 
medical oncology center in Figure 6-5 features a large 
saltwater aquarium in the main lobby, adjacent to a 
resource library (Figure 4-50). 



Interior Design 

There are no special restrictions in terms of interior 
design for this specialty with the exception of what com- 
mon sense would dictate for the lab and nurse station. 
Chemo infusion can be carpeted, have textured vinyl 
wallcoverings, and use wall sconce lighting. Preferably, 
ambient light will not come from fixtures located direct- 
ly over patient chairs. (Some feel carpet should not be 
used because drops of chemotherapy agents that spill 
must be cleaned up and they are hard to inactivate 
without using a bleach-and-water solution. Options 
would be a wood-look sheet vinyl or a solution-dyed 
carpet that can be cleaned with bleach.) Glare must be 
considered from the standpoint of a patient reclining in 
a chair. Even downlights with a polished Alzak® (looks 
like polished chrome) interior and compact fluorescent 
lamps can create a tremendous hot spot directly in the 
eyes of a seated patient. Lighting that can be adjusted 
by the patient, or increased when the nurse needs it, 
would be optimal. 

The oncologist's practice is composed of equal num- 
bers of men and women; therefore, the design style, col- 
ors, and vocabulary of details should reflect the commu- 
nity the practice serves. Recliner chairs in the infusion 
room need not be covered with uncomfortable — and cold 
to the touch — vinyl upholstery fabric but must be wiped 
clean of blood, IV solutions, and chemotherapy spills. 
Woven Crypton® provides the same benefits, yet has the 
ambience of a fine-woven fabric with no limitation on 
beautiful colors and patterns. 



152 Medicine: Specialized Suites 




Figure 4-50. Reception/waiting area. Hope Cancer Care Center, Morton Grove, IL. (Architecture and interior design: Mekus Studios, Chicago, IL; Photographer: Jon 
Miller® Hedrich Blessing.) 



Oncology 153 




Figure 4-51. Examination room, vascular surgery. (Interior architecture and Design: 
Jain Malkin Inc.; Photographer: Steve McClelland.) 



GENERAL SURGERY 

This is a low-volume practice in large part dependent on 
referrals from primary-care physicians. The suite can be 
small, because most of a surgeon's work is done in a hos- 
pital. Patients are examined and interviewed preopera- 
tive^ and postoperatively in the office, and sutures may 
be removed or dressings changed. 

A surgeon's office (solo practitioner) will usually con- 
tain two or three standard- sized exam rooms (Figure 
4-51), a large consultation room (12X12 or 12x14 
feet), a small business office, a waiting room, and a 
restroom. (If one exam room is larger — 10X12 feet — it 
can be used for minor surgery.) A small nurse station, a 
niche in the corridor, will suffice for the sterilization of 
instruments and storage of dressings and supplies 
(Figure 4-52). An undercounter refrigerator should be 
built into the cabinet. Figure 4-53 diagrams the relation- 
ship of rooms. 

The waiting room need not accommodate more than 
eight chairs, since patients are well scheduled and usual- 
ly do not have to wait a long time. The waiting room in 
Color Plate 14, Figure 4-54, was designed for a promi- 
nent vascular surgeon and reflects his love of contempo- 
rary art and architecture. It's a serene retreat for patients 
who have an abundant choice of current magazines and 
dozens of art books while they sip tea or freshly brewed 
coffee. Surgeons usually perform surgery in the morning 
and see patients in the office during the afternoon. The 
consultation room is larger than for many medical spe- 
cialties because it may be used for consulting with 
patients. A double-panel X-ray view box should be locat- 
ed near the desk. 

In a two-surgeon office, it is likely that schedules will be 
arranged so that one sees patients in the office while the 
other does surgery. In a three-surgeon practice, perhaps 
two would see patients at the same time, sharing four or 
five exam rooms and a minor surgery room (Figures 4-55 
and 4-56). 

In a one-physician practice, two employees can usual- 
ly run the business office — answering the phone, book- 



154 Medicine: Specialized Suites 




GENERAL SURGERY (compact office) 

1280 SF 
Figure 4-52. Space plan for general surgery, 1280 square feet. (Design: Jain Malkin Inc.) 







NUR5& exam I 



Figure 4-53. Schematic diagram of a general surgery suite. 



ing appointments, handling insurance, and billing 
patients. A three- or four-physician practice will have an 
expanded business office with more staff performing the 
tasks of reception, bookkeeping, insurance, and surgery 
scheduling (Figure 4-55). 



All rooms of this suite may be carpeted. The decor 
should be cheerful with warm colors but, above all, it must 
convey a solid, conservative image due to the nature of 
the specialty. A patient wants to think of a surgeon as a 
serious person not subject to frivolities and trendy decor. 



General Surgery 155 



50-6" 




GENERAL SURGERY 



2301 SF 
Figure 4-55. Space plan for general surgery, 2301 square feet. (Design: Jain Malkin Inc.) 



156 Medicine: Specialized Suites 



70'- 0" 



CONSULT 




EXAM 



CONSULT 




EXAM 



^ 



EXAM 



ri 



CONSULT 








■ B 


en 




MINOR SURG. 


I 
1 
1 

(J 

i 

i 

1 












i 



GENERAL SURGERY 



3080 SF 



Figure 4-56. Space plan for general surgery, 3080 square feet. (Design: Jain Malkin Inc.) 



General Surgery 157 



Table 4-3. 

Analysis of Program. 

Otolaryngology 



No. of Physicians: 


1 






2 




Exam Rooms 3@ 


10 x 10 


= 300 


5@ 


10 X10 


= 500 


Consultation Rooms 


12 X 14 


= 168 


2@ 


12 X14 


= 336 


Business Office 


12 X 18 


= 216 




12 X18 


= 216 


Nurse Station/Lab 


8X10 


= 80 




8 X12 


= 96 


Waiting Room 


14 x 16 


= 224 




14 X20 


= 280 


Audio Room with Dispensing 


8X18 


= 144 




8 X18 


= 144 


Toilets 2@ 


7X8 


= 112 


2@ 


7X8 


= 112 


Minor Surgery 


12 X 12 


= 144 




— 




Outpatient Surgery 












Operating Room 


— 






14 X16 


= 224 


Scrub 


— 






4X5 


= 20 


Nurse Station 


— 






6X8 


= 48 


Soiled Utility 


— 






8X8 


= 64 


Cleaned Utility 


— 






8X8 


= 64 


Med Gas Storage 


— 






3X4 


= 12 


Janitor Closet 


— 






3X4 


= 12 


Equipment (air and suction) 


— 






4X4 


= 16 


Recovery (2 beds) 


— 






10 X14 


= 140 


Storage 


8X8 


= 64 




8X8 


= 64 


X-Ray (Optional) 


— 






9 X12 


= 108 


Darkroom (Optional) 


— 






6X6 


= 36 


Staff Lounge 


10 x 10 


= 100 




10 X12 


= 120 


Subtotal 




1552 ft 2 






2612 ft 2 


20% Circulation 




310 






522 


Total 




1862 ft 2 






3134 ft 2 



Note: The one-physician suite outlined above would serve an otolaryngologist who does not do office- 
based surgery; the two-physician suite is designed for practitioners who do. 



OTOLARYNGOLOGY 

An otolaryngologist treats diseases of the ears, nose, and 
throat and tumors of the head and neck. The surgical spe- 
cialty is more commonly known as ENT (ear, nose, and 
throat), and its practitioners sometimes practice facial 
plastic surgery as well. 

For maximum efficiency, a solo practitioner needs 
three examination rooms, a waiting room that seats 10 or 
1 1 persons, an audio test room and hearing aid dispens- 
ing area, a minor surgery room (or if facial plastic surgery 
is practiced, an outpatient surgery suite and recovery 
room), occasionally an X-ray room and darkroom, a busi- 
ness office, a consultation room, and a nurse station/lab 
(Figures 4-57 and 4-58). A two-physician suite may not be 
much larger, but would have an additional consultation 
room and two or three additional exam rooms. Figure 
4-59 shows the relationship of rooms. 

In-house X-ray is declining due to OSHA and other reg- 
ulatory issues, the cost of a technician, and liability in 
reading films. In addition, the most complex problems are 
now diagnosed by CT scan or magnetic resonance imag- 
ing (MRI), which have become the standard of care. 

The consultation room is large (12X14 feet) since 
patients are often brought into this room to discuss fees for 
surgery or to discuss the feasibility of a surgical proce- 
dure. The X-ray room can be as small as 8X12 feet, 
depending on the physician's equipment, since films are 
limited to the head and neck. The reader is referred to 
Chapter 3 for space-planning details of an X-ray room, 
control area, darkroom, and lead shielding. The darkroom 
can be small, since the physician will probably have a 
tabletop model automatic film processor similar to the kind 
used by dentists. The designer must obtain the specs on 
utility requirements from the manufacturer of the unit. 



Exam Rooms 

Examination rooms should be 10x10 feet ideally with the 
sink cabinet located on the long wall. A motorized exami- 
nation chair (see Figure 4-60) is located in the center of 



158 Medicine: Specialized Suites 



VACUUM/GENERATOR 
+ STORAGE 




ff ii j^ 



OTOLARYNGOLOGY (with surgery suite) 

2883 SF 
Figure 4-57. Space plan for otolaryngology (with surgery suite), 2883 square feet. (Design: Jain Malkin Inc.) 



Otolaryngology 159 



Figure 4-58. Space plan for otolaryngology, 2698 
square feet. (Design: Jain Malkin Inc.) 



^ 



V 



£?TV?LAR.YMcV£L^Y 




Figure 4-59. Schematic diagram of an otolaryngology suite. 



#- 



59-6" 



-/■ 



OFF. MGR. 




si ~~L £Xm1 y\ Zl exai v1 ZL zxm */\ " ^^™ 

/ \m\ ( \\m ( llngj ( \^^ 




CONSULT 



OTOLARYNGOLOGY 

2698 SF 




RECOVERY 



EZ1 



□ 



y-^r\ — 



STAFF LOUNGE 



c 




NURSE 
STA. 



? 



I Si 



S 



DKRM. 



u 



58 

OHTROL 
ONSOLE 

□ 



X-RAY 



n 

JAN. 



-s— - 



WORK ROOM 



MINOR SURG. 



T 



-X- 



29-6" 



-X 



160 Medicine: Specialized Suites 




Figure 4-60. ENT cart. (Photo courtesy: Midmark Corporation, 
Versailles, OH.) 



-,>, %1 




Figure 4-61. ENT cabinet for otolaryngology exam room. Deluxe 
MaxiCabinet. [Photo courtesy: Global Surgical Corporation, St. Louis, 
MO.) 



the room with the patient facing the door. The chair swivels 
360 degrees. The physician works off of a cart along the 
wall, to the right of the patient. Most of the time, the physi- 
cian is seated on a stool with casters. Each exam room 
needs an X-ray view box recessed into the wall. 

The unit from which the physician works is usually a 
specialized manufactured instrument cabinet on casters 
(Figures 4-60 and 4-61) containing a suction unit and 
pump, compressed air, a cautery, an electrical panel for 
instruments, racks for solution bottles, and a shelf and 
drawers for medications, cotton jars, irrigation syringes, 
and atomizers. The unit also has a pull-out writing shelf. 



Approximately 23 inches widex18 inches deepx46 
inches high at the rear panel, it requires a grounded duplex 
outlet. Some units have Corian® tops and plastic laminate 
faces. [These are often referred to as Storz/SMR carts by 
physicians, but the SMR division of Storz Instrument was 
acquired by Global Surgical Corp. in 1994.] 

Sometimes the medical examination cabinet is pur- 
chased without suction and air features, in which case the 
designer needs to provide a vacuum system within the 
suite. Many physicians prefer central suction. A small 
room, 4 feet 6 inches X5 feet, should be provided close to 
the examination rooms to eliminate long-distance piping. 



Otolaryngology 161 



Vacuum pumps and air compressors are noisy, so the 
walls of this room should be well insulated. Usually, two 
separate 20-ampere circuits will be required. A local vacu- 
um contractor or a competent plumbing contractor can 
provide the designer with specs on the equipment and will 
install the plastic piping. The piping would be done after 
the HVAC (heating, ventilating, and air conditioning) has 
been completed, but before the partitions are closed up. 

One exam room may be slightly larger to accommodate 
digital fiber-optic diagnostic equipment (Figure 4-62). This 
involves a Sony monitor, an image capture device (minia- 
ture camera on tip of fiberoptic scope), and a printer. Both 
physician and patient can watch the procedure on video 
and the patient can leave with a photo. With a different 
probe, one can examine the ear, nose, throat, and larynx. 

A nice feature in exam rooms and the recovery room is 
a wall-mounted cosmetic mirror — perhaps a small plastic 
laminate cabinet with two hinged doors, which, when 
opened, reveal a good-quality mirror and two rows of 
makeup lights on either side. A light over the mirror will 
only create a shadow on the face. In designing the mirror, 
being able to visualize the head from both sides, or pro- 
files, is desirable. A dressing area is not required in ENT 
exam rooms. 



Office-Based Surgery 

If the physician does only ENT and no facial plastic sur- 
gery, a minor surgery room (refer to Chapter 3) would be 
used for special procedures and for emergency care. As 
the practice matures, some otolaryngologists tend toward 
more cosmetic and reconstructive facial plastic surgery 
because it is more lucrative and, perhaps, more interest- 
ing than routine ENT procedures. Procedures such as 
nose reconstruction, facelifts, eye tucks, and face peels 
as well as routine tonsillectomies and sinus surgery may 
be performed in the office in a well-equipped outpatient 
surgery room with ancillary recovery room and scrub and 
prep areas (Figure 4-57). Regulations have tightened on 
office-based surgery, requiring far more space than prac- 
titioners previously allocated. 




Figure 4-62. Diagnostic ENT VideoScope enables the patient or family 
member to visualize the medical problem and also facilitates telemedi- 
cine consultations. {Photo courtesy: AMD Telemedicine, Lowell, MA.) 



The surgery room should contain one wall of built-in cab- 
inets, and the sink should have a plaster trap and foot-lever 
control for hot, warm, and cold water. Scrub and prep can 
be done in the surgery room if the room is large enough and 
if patient volume is low. An electrical outlet is required in the 
floor for the motorized table. Other electrical outlets and 
connections for suction, compressed air, and instruments 
should be located by the physician, since this room allows 
for a variety of options with respect to work habits. The 
reader is referred to Plastic Surgery section for a detailed 
discussion of an office-based surgery suite, requirements 
for third-party payers, and accreditation issues. 



Audio Testing 

A basic part of an otolaryngologist's practice involves 
diagnosing and treating patients with a hearing loss. An 
audiometric test booth is used for testing hearing. It is a 
soundproofed booth approximately 30X40 inches (or 



162 Medicine: Specialized Suites 




Figure 4-63. Prefabricated audio booth for testing hearing. 
(Photographer: Jain Malkin.) 



may be larger) with a door at one end. The patient sits 
inside and listens to sounds of different frequencies 
through headphones. The technician or audiologist sits 
outside the booth, at a counter facing the patient, and 
looks into the booth through a window so that the patient 
is always in view (Figure 4-63). This countertop contains 
the audio equipment from which sounds are transmitted 
to the patient in the booth. The patient's responses are 
digitally recorded, and a graph of hearing loss is pro- 
duced for the physician to evaluate. 




Figure 4-64. Audio booth with cartoon design. [Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 

The audio booth is available as a prefabricated unit 
(Figure 4-64) that breaks down into components (the large 
ones) and is assembled in the room by an installation 
technician. Smaller units are preassembled. The booth 
has a roof-integrated ventilation system, lighting, and a 
prewired medical jack panel to connect it to the testing 
equipment. The audio testing room must be located in a 
quiet part of the suite, away from the heavy traffic of the 
waiting room and business office. If the prefab booth is to 
be handicapped accessible, it will require a large room 
and a small ramp to get over the 4-inch-high "ledge." 

A custom audio booth can be built on the job, but rig- 
orous construction specifications must be adhered to in 
order to achieve a sound transmission class of 55 to 60 
decibels. Double-stud walls with several layers of sound 
board, insulation batting, and a solid-core door with an 
acoustic seal on all sides would be required. 



Otolaryngology 163 



Hearing Aid Dispensing 



Interior Design 



The audiologist will make a mold of the ear and fit and 
adjust the hearing aid when it arrives. From time to time, 
patients will return to have their hearing aids fine tuned. 
This can take place in the same room as the audio test- 
ing if a desk is provided for the audiologist and if there is 
suitable storage. An L- or U-shaped desk works best. The 
computerized equipment that tunes the hearing aid sits 
on the desk and the patient sits to the side of the desk 
facing the audiologist (Figure 4-65). 



There are no special requirements for interior design in 
this suite. If the practice tends toward facial plastic sur- 
gery, the office design should reinforce the image of the 
surgeon as a successful, skilled professional with refined 
aesthetic taste. The reader is referred to the Plastic 
Surgery section in this chapter for additional discussion of 
this topic. 



OPHTHALMOLOGY 




Figure 4-65. Audiologist's desk for fitting hearing aids. {Photographer: Jain Malkin.) 



This specialty is characterized by a variety of options in 
suite design. Therefore, the individual practitioner must 
make the basic decisions on preferred work habits before 
the designer can begin. 

The constant demand for specialized eye care means 
that the ophthalmologist may attain a capacity patient load 
within the first two years of practice. Thus, it is important to 
project at the outset what the ophthalmologist's space 
needs will be in two or three years. Often, young ophthal- 
mologists setting up their first offices will try to be too eco- 
nomical. They set up an undersized office based on their 
patient projection (usually underestimated) at that moment. 
Then, for the remainder of their lease (usually five years), 
they are handicapped by a small, poorly laid out office, 
which greatly inhibits the growth of their practice. 



Patient Volume 

Many ophthalmologists schedule three patients per hour 
for regular eye examinations, although the testing portion 
of the examination and updating the patient's medical his- 
tory is done by a tech or medical assistant prior to the 
physician entering the room. Added to that are unsched- 
uled patients — emergency and trauma — and postopera- 
tive patients, and it is not unusual for an ophthalmologist 
to see four or five patients an hour. Individual practice 
habits may differ, with some doctors spending more time 



164 Medicine: Specialized Suites 



informally chatting with patients than those who choose 
to work in a more restricted, tightly scheduled manner. 
The more relaxed ophthalmologist may see only two 
patients per hour, particularly if he or she does all the 
testing with little assistance from aides, but this is rare, 
especially with declining reimbursement and the pres- 
sures of managed care. 



Required Rooms 

A solo practitioner needs at least two refraction rooms, 
plus a third multipurpose or surgery/treatment room 
(Figure 4-66). While a patient whose examination has 
been concluded is gathering up possessions and receiv- 
ing medications and instructions from the tech or aide, 
the doctor has already stepped into the next refraction 
room and has begun to examine the patient with no loss 
of time. The surgery room can be used for removing a for- 
eign body from the eye or for other emergency visits, or 
the doctor may see an unscheduled patient in this room 
while he or she is between patients without interrupting 
scheduled patients in the refraction rooms. The surgery 
room can also be used for photography or for visual fields 
testing or othoptic evaluations. Some ophthalmologists do 
not require a large multipurpose treatment room as they 
do all their procedures in the exam room, including 
removal of cysts, suturing lacerations, and so on. 
However, an ophthalmologist who does cosmetic proce- 
dures on eyelids and forehead can perform these in the 
office in a surgery room. These are typically done using 
local anesthetic. 

An ophthalmologist does not need a nurse station or 
lab as such, but it is advisable to provide a work space in 
a niche off the corridor (Figure 4-67) for an assistant or 
tech. This is where phone calls can be received or made 
to reschedule patients, prescriptions authorized, and 
medications dispensed. Ophthalmologists dispense a 
number of eyedrops and medications, which may be 
stored in a rack in each examining room or at the assis- 
tant's work area. 



Table 4-4. 

Analysis of Program. 

Ophthalmology 



No. of Physicians: 






1 








2 








4 




Refracting Rooms 


3@ 


10 


X12 


= 360 a 




4 


total 


= 700 b 


8@ 


10 


X 12 


= 960 


Surgery 




11 


X12 


= 132 


2@ 


12 


x 12 


= 288 




12 


X 22 


= 264 


Consultation 




10 


X12 


= 120 


2@ 


10 


x 12 


= 240 


4@ 


10 


X 12 


= 480 


Fields Room 




8 


X 8 


= 64 






— 






8 


X 8 


= 64 


Data Collection 






— 






10 


x 10 


= 100 




10 


X 14 


= 140 


Waiting Room 




12 


X18 


= 216 




16 


X28 


= 448 




22 


X 26 


= 572 


Drops 




6 


X10 


= 60 




8 


X 12 


= 96 




Use Waitinc 


Room 


Toilets 


2@ 


7 


x 8 


= 112 


2@ 


7 


x 8 


= 112 


2@ 


7 


X 8 


= 112 


Business Office 




12 


X14 


= 168 




12 


x 16 


= 192 




12 


X 20 


= 240 


Storage 




4 


x 6 


= 24 




6 


x 8 


= 48 




6 


X 8 


= 48 


Optician, Lab, and 


























Contact Lens 




10 


X24 


= 240 


(Nondispensing Physician) 




18 


x 30 


= 540 


Staff Lounge 






— 






8 


x 10 


= 80 




12 


x 12 


= 144 


Subtotal 








1496 ft 2 








2304 ft 2 








3564 ft 2 


20% Circulation 








299 








461 








713 


Total 








1795 ft 2 








2765 ft 2 








4277 ft 2 



"Using mirrors. 

'Twenty-four-foot refracting rooms (two "interlocking" together occupy approximately 10x35 ft). 



<?niTtV\UM£?l_.£>6?Y 




Figure 4-66. Schematic diagram of an ophthalmology suite. 



Ophthalmology 165 



60'-0" 




OPHTHALMOLOGY (dispensing physician) 



1920 SF 
Figure 4-67. Space plan for ophthalmology, 1920 square feet. {Design: Jain Malkin Inc.) 



LEGEND 

ET EXAMINATION TABLE 

IT INSTRUMENT TABLE 

S STOOL 

TS TANGENT SCREEN 

PP PROJECTION PERIMETER 

TLS TRIAL LENS SET 

SC SCREEN 

PR PROJECTOR 

CS CHAIR & STAND 



Optical Dispensing 

It is not uncommon for ophthalmologists to practice as solo 
practitioners with the help of an assistant or technician. An 
optician may also be part of the practice, in which case an 
area approximately 10X24 feet is needed, divided into a 
lab, a contact lens area, and a fitting area (Figures 4-67 
and 4-68). The lab has walls lined with cabinets and work 
counters and requires shadow-free lighting. 



The contact lens area requires a small fitting table 2x4 
feet with a mirrored top. The patient sits on one side and 
the optician on the other. The room may also have a stor- 
age cabinet and a small sink. The fitting area has a long 
table divided into a number of fitting stations, each with a 
mirror, and it may have panels of eyeglass frames (frame 
bars) located on either side of the patient. The optician 
sits on a stool behind the table and works from drawers 
and cabinets to the side and behind. Attractive wall frame 



166 Medicine: Specialized Suites 



79-0' 




LEGEND 

ET EXAMINATION TABLE 

IT INSTRUMENT TABLE 

S STOOL 

NCT NON-CONTACT TONOMETER 

TS TANGENT SCREEN 

PP PROJECTION PERIMETER 

TLS TRIAL LENS SET 

SC SCREEN 

PR PROJECTOR 

CS CHAIR & STAND 



OPHTHALMOLOGY (dispensing physician) 



4774 SF 
Figure 4-68. Space plan for ophthalmology, 4774 square feet. {Design: Jain Malkin Inc.) 



Ophthalmology 167 



bars can be purchased ready made, or they may be 
designed and custom fabricated to hold the many eye- 
glass frames to be displayed. 

Ophthalmologists who offer the services of an optician 
are called dispensing physicians. As a marketing strategy, 
it is advisable to give as much visibility as possible to the 
dispensing area so that waiting patients are tempted to 
walk over and look at the frames. 



Multipurpose Exam Room 

Ophthalmologists used to arrange their offices so that dif- 
ferent tests were performed in different rooms. Some oph- 
thalmologists may still practice that way. However, it is far 
more efficient for the patient to remain in one room. Each 
time the patient has to gather his belongings and move to 
another room, then again get comfortable, valuable time 
(and money) is lost. For most ophthalmology practices, a 
complete examination and treatment can be done in the 
same room with the patient in the same chair. 



Refraction Room 

The most important room is the refraction room, a multi- 
purpose examination room with equipment and instru- 
ments grouped around the patient and the doctor sitting 
either in front of the patient or just to one side. Right- 
handed physicians may prefer to examine from the 
patient's right side although, if the physician wants to 
write notes while facing the patient, the preference may 
be to locate the cabinet (with writing desk) to the left of 
the patient as in Figure 4-67. The dimensions of this room 
are crucial, and both the ophthalmologist's work habits 
and instruments will dictate the critical distances that 
must be observed. 

Refraction rooms have two basic sizes. Since a stan- 
dard eye chart is designed for a distance of 20 feet from 
chart to patient's eye, the traditional refraction room is 
approximately 24 feet long (20 feet for the refraction lane 
plus 4 feet for the examining chair and space to walk 



around it) as in Figure 4-68. However, with the aid of pro- 
jectors and mirrors, the room length may be reduced to 
12 to 14 feet. A 9- or 10-foot-widex12-foot-long room 
would be suitable. Today it is rare to find refraction rooms 
longer than 12 feet. 

To compensate for a room length of less than 24 feet, 
two mirrors are placed on the wall in front of the patient, 
and a screen is placed on the wall behind the patient 
(Figures 4-67 and 4-69). A projector (Figure 4-70), usual- 
ly wall mounted, projects the text characters onto one of 
the front mirrors, which, in turn, projects it back to the 
screen behind the patient. The second mirror, in front of 
the patient, reflects the image from the rear screen. The 
refracting lane, in this case, is the distance measured 
between the second mirror and the screen plus the dis- 
tance between the mirror and the patient. The letters of 
the eye chart can be adjusted in size by the projector so 
that correct visual acuities can always be maintained. 

There are several types of procedures performed in the 
refracting room, but the primary task is to determine the 
refractive power of the eye. To do this, the tech or physi- 
cian selects various lenses from a partitioned rack (Figure 
4-71), a trial lens box (approximate size 12 1 / 2 x20 1 / 2 x2 1 /2 
inches), and places them in a holder through which the 
patient looks. The patient is asked to read the test letters 
to determine which lens is best. Sometimes a refractor, an 
instrument containing lenses, is used. 

The interior of the eye, the fundus, is examined by an 
ophthalmoscope, a handheld light source, while the con- 
junctiva, lens, iris, and cornea (the front portions of the 
eye) are examined with a slit lamp, an illuminated micro- 
scope (Figure 4-72), which may be mounted on an arm of 
the instrument stand (Figure 4-73) or may be on a mobile 
instrument table. A keratometer (Figure 4-74) measures 
the curvature of the cornea. The Radiusgauge™ in Figure 
4-75 measures the curvature and thickness of contact 
lenses. 

A direct ophthalmoscope (Figure 4-76) is used to view 
and illuminate the retina, head of the optic nerve, retinal 
arteries, and vitreous humor even through an undilated 
pupil. The focus in the eyepiece is equal to the image on 
the video monitor. 



168 Medicine: Specialized Suites 



Jf- 



76-0" 



-X- 



REFR. RM. IT 

I/WRROR CS Q 



REFR. RM. 

l/MIRROR CSQ 



DESK JKJ-t; 




REFR. RM. I IT 
L/M1RROR CSQ 



DESK $sylz 



a- 



TOILET 



© © 



TREATMENT RM. 



KwRROR csO 

REFR. RM. 
PR Y " 



DESK SlSL. 



KjflRROR csQ 



REFR. RM. 



OPHTHALMOLOGY (non-dispensing physician; 

3344 SF ' 

Figure 4-69. Space plan for ophthalmology, 3344 square feet. (Design: Jain Malkin Inc.) 



STAFF 
ENTRY 



PVT. OFFICE 



STORAGE 



TREATMENT RM. 



® 



STOR. 



PVT. OFFICE 



LEGEND 

ET EXAMINATION TABLE 

IT INSTRUMENT TABLE 

S STOOL 

NCT NON-CONTACT TONOMETER 

TS TANGENT SCREEN 

PP PROJECTION PERIMETER 

TLS TRIAL LENS SET 

SC SCREEN 

PR PROJECTOR 

CS CHAIR & STAND 



Ophthalmology 169 






Figure 4-70. Ophthalmology automated chart projector 
(can be wall mounted). (Photo courtesy: Leica 
Microsystems Inc., Bannockburn, IL.) 



Figure 4-71. Trial lens box. [Photo courtesy: Marco Ophthalmic, 
Jacksonville, FL.) 



Figure 4-72. Slit lamp. (Photo courtesy: Marco 
Ophthalmic, Jacksonville, FL.) 



Examining chairs are available in tilt or nontilt models. If 
the physician prefers to write notes at a desk that enables 
him or her to face the patient, the room would be set up 
with the chair positioned so that the instrument stand con- 
sole is to the patient's right, although this means that a 
right-handed physician is always reaching for instruments 
with the left hand as well as reaching across the patient. 
An alternative is a mobile trial lens cart with a pull-out writ- 
ing shelf. Located to the patient's right, with the instrument 
stand on the patient's left (the physician's right as he or 
she faces the patient), it allows the physician to face the 
patient while writing notes and use the right hand both to 
select trial lenses and to manipulate the slit lamp and 
other instruments. The chair should be positioned in the 



room so that the physician can walk behind it (allow 3 to 4 
feet behind it) even when the chair is in the reclined posi- 
tion. The chair and attached instrument stand console 
together are approximately 4 feet wide (Figure 4-73). A 
clear space of 24 to 30 inches to the right side of the 
patient and 5 to 6 feet to the left is desirable (measured 
from the center of the chair). As with any medical equip- 
ment, the designer must verify dimensions and critical 
spatial relationships before designing the room. This chap- 
ter lists general dimensions, but each manufacturer's liter- 
ature must be consulted for specifics. 

The physician may work off of the instrument stand as 
well as the sink cabinet located to the left of the patient. 
The instrument stand console may be specially wired so 



170 Medicine: Specialized Suites 






Figure 4-74. Keratometer. {Photo courtesy: Marco Ophthalmic, 
Jacksonville, FL.) 



Figure 4-75. Radiusgauge™ used to measure 
hard or gas-permeable contact lenses. (Photo 
courtesy: Marco Ophthalmic, Jacksonville, FL.) 



Figure 4-73. Chair and instrument stand. Note chart projector 
mounted on post and slit lamp on table. (Photo courtesy: Marco 
Ophthalmic, Jacksonville, FL.) 




Figure 4-76. Direct video 
ophthalmoscope enables the 
patient or family member to 
see what the physician is 
seeing and also facilitates 
telemedicine consultations. 
(Photo courtesy: AMD 
Telemedicine, Lowell, MA.) 



Ophthalmology 171 




Figure 4-77. Refraction room (Design: Jeffrey B. Morris, M.D.; Photographer: Robinson/Ward.) 

that the physician can control the room lights, fixation 
light, projection chart, and other instruments from it. Or, 
the sink cabinet may be extended to include a knee space 
and an electrical panel for remote control of the room's 
overhead lights, projector, fixation light, and nurse call 
buzzer. (Switches and controls may be located on the 
face of the cabinet or in the knee-space opening so that 
they are within easy reach of the ophthalmologist during 
the examination.) Thus, the ophthalmologist, from a seat- 
ed position alongside the patient, may control illumination 
and instrumentation from either the instrument stand or 
the wall cabinet, or both (Figure 4-77). 

Room lights should have a three-way switch so that 
they can be controlled from the wall and the console, and 
they should have a dimmer control. (Local codes must be 



checked with reference to controlling room lights from the 
instrument stand. Low-voltage wiring is usually required.) 
Indirect lighting works best in an ophthalmology exam 
room. For example, fluorescent lamps around the perime- 
ter of the room with uplighting source shielded by the fix- 
ture eliminate the brightness of overhead lights when 
patients' eyes are dilated. 

Other electrical requirements for the room include an 
outlet for a fixation light mounted on the wall at approxi- 
mately a 72-inch height directly behind the patient; an out- 
let for the projector, usually at a 60-inch height on the wall 
to the left of the patient or behind the patient (the design- 
er must specify wood blocking in the wall to support the 
weight of the projector); a duplex outlet above the coun- 
tertop for miscellaneous instruments and recharger mod- 
ules for the cordless hand instruments; and a floor outlet 
(15-ampere circuit) for the instrument stand console. 

One duplex outlet should be located at a 12-inch height 
on the wall to the left of the examining chair, and all out- 
lets should be grounded. The electrical requirements of 
refraction rooms are highly specialized. A thorough 
review of the practitioner's habits and specific instrumen- 
tation is necessary before planning the electrical layout. 

The trial lens case may be placed on a countertop 
(Figure 4-71), or it may fit in a drawer or be built into a 
mobile cart designed for that purpose. If it is to fit in a 
drawer, the designer must determine if the rack should be 
tilted for easier visibility, in which case the drawer must be 
deeper. 

A more contemporary style of refraction chair and 
instrumentation is shown in Figure 4-78. Capable of per- 
forming all refraction procedures by remote control (offer- 
ing greater flexibility to the operator), it offers direct wire- 
less data transfer and speeds the examination process. 
Moreover, it works well for disabled patients who can 
remain in the wheelchair and pull up under the shelf. The 
phoropter (eyepiece unit) slides up and down the pole to 
adjust height. The trial lens case fits into the top drawer of 
the pedestal. The room requires the standard projector, 
mirrors, and screen. An interesting feature is that the 
patient's current prescription for lenses can be loaded 
into the computer to be used as a comparison with the 



172 Medicine: Specialized Suites 



current exam and the new prescription can be down- 
loaded to an electronic medical record, enabling both 
uploading and downloading of data. 

All refracting rooms should be exactly alike in layout, 
arrangement of instruments, and quality of equipment. 
If one room has a better slit lamp than another, the 
rooms will not get equal usage. Patients will be shifted 
around so the doctor can use favored equipment, 
defeating the basic efficiency of the suite. 

The distance the doctor must walk between refrac- 
tion rooms should be minimal. To this end, some oph- 
thalmologists request connecting doors between two 
refraction rooms (Figure 4-68). Although it saves steps, 
it creates an acoustic problem. And since many persons 
with poor eyesight happen to be elderly, they may also 
suffer from a hearing loss, which means the doctor may 
have to shout to be understood — all the more reason to 
provide good sound insulation around these rooms and 
walls that continue beyond the finished ceiling. 



Mydriatic Area 

Prior to an eye examination, the patient may receive 
eyedrops to dilate the pupil. The patient is often asked 
to wait in a secondary waiting area adjacent to the 
refraction room called a drop or mydriatic room for 15 
to 20 minutes before being admitted to the refraction 
room for the examination. 



Automated Refraction 

An automated refractor (Figure 4-79) is an electronic 
tabletop instrument (also available as a handheld unit 
as in Figure 4-80) for objectively measuring the 
patient's visual acuity. It is commonly used by a techni- 
cian, thereby reducing the number of physician-per- 
formed refractions and streamlining those that are nec- 
essary. One of the advantages of this unit, in addition to 
the time it saves over the conventional method of 
refraction, is that it does not rely on the patient's sub- 




Figure 4-78. Auto Optester remote 
control refraction instrument with 
Os-Wing ophthalmic console sys- 
tem. (Photo courtesy: Nikon 
Instruments Inc., Melville, NY.) 



Figure 4-79. Automated refractor. 
[Photo courtesy: Marco Ophthalmic, 
Jacksonville, FL.) 




Ophthalmology 173 





Figure 4-80. Handheld Retinomax K-Plus2 Auto refractometer. (Photo courtesy: Nikon Instruments Inc., Melville, NY.) 

jective comparison: Is this clearer than that? The patient 
looks into the viewing window of the unit and adjusts a 
knob until the image is in focus. The machine automatical- 
ly gives a digital readout of the patient's visual acuity. It can 
also compare the patient's current prescription with the 
new one. 

When used as a general screening device, this machine 
would be located in the data collection room along with the 
other instruments used by aides (Figure 4-69). 

After a patient has been refracted by this instrument, 
he or she moves to an examination room where the oph- 
thalmologist would review the findings and study the 
patient's medical history. 

In spite of the advantages afforded by an automated 
refractor, many ophthalmologists prefer the traditional 
method of refraction done in the examination room. It is 
generally performed by a technician or aide who also 
takes the patient history in advance of the ophthalmolo- 
gist's entering the room. The ophthalmologist then exam- 



ines the eye with a slit lamp and may use the Non- 
Contact™ Tonometer (Figure 4-81) to check for glaucoma 
or perform other procedures, as required, to diagnose the 
patient's problem. 



Visual Fields 

The charting of visual fields used to be done with a tan- 
gent screen, which is a piece of black felt with meridians 
marked off (Figure 4-82), but is now commonly done with 
automated digital equipment. As tangent screens are still 
in use, the concept will be explained. Tangent screens 
may be rigid or roll-up, the former being preferred 
because they permit greater accuracy. They are available 
in four sizes, ranging from 1 to 2 meters, the smaller 
screen giving the smallest amount of information. A 1.5- 
meter screen is commonly used, and if it is placed in a 
dedicated room, the room need be only 8x8 feet. A 1- 
meter screen needs a room only 6x6 feet in size. 

The tangent screen may be in the data collection room, 
in a refracting room, or in a visual fields room, depending 
on the practitioner's preference and the composition of 
the practice. A glaucoma specialist may have one in each 
refracting room. Others may have only one screen in the 
data collection room. 

The patient sits at a specified distance from the screen 
(which resembles a target), and pins are placed in the felt 
to chart the limits of the patient's visual field. If the screen 
is placed in the refraction room, it is convenient to locate 
it on the wall behind the patient. Thus, the physician can 
spin the patient's chair around to face it. The chair must 
be 1 .5 meters (60 inches) away from the screen (with a 
1 .5-meter screen). 

However, the tangent screen is a basic screening device 
and not terribly accurate, since one has no control over 
movement of the patient's head. Perimetry is a more 
advanced method of doing peripheral and central fields. An 
automated projection perimeteris a computerized piece of 
equipment that sits on a 24x30-inch instrument table 
(Figure 4-83). The patient's visual field is charted automat- 
ically and accurately since the patient's head is firmly held. 



174 Medicine: Specialized Suites 



The instrument fits in a room as small as 6X6 feet. It may 
be placed in a visual fields room or in a data collection 
room, but the room's illumination must be controlled by a 
dimmer, since the procedure is done in a dark room. Not all 
ophthalmologists will have this piece of equipment. 



Procedure/Surgery Room 

A number of procedures can be done in a large (12x14 
feet) room similar to special procedure rooms in primary- 
care offices. A full wall of casework should be provided, 
with an undercounter refrigerator and a sink with foot- 
pedal control. An autoclave for sterilizing instruments will 
sit on the countertop. A ceiling-mounted surgical light is 
required along with a sheet vinyl floor. 



Lasers 

Laser surgery makes possible the correction of many 
vision problems on an outpatient basis in the ophthalmol- 
ogist's office. Lasers are used to treat diabetic retinopa- 
thy, macular degeneration, retinal tears, glaucoma, and 
retinal vein occlusion and to open the clouded posterior 
capsule that sometimes forms following cataract surgery. 

Laser light is within the normal visible spectrum, but it 
is coherent light of a single wavelength — all the energy 
works together and in one direction. This allows it to be 
focused precisely on a certain point. 

Choosing a wavelength color that the eye tissue being 
treated can absorb, controlling the power and time of expo- 
sure, and varying the size of the laser beam allow the physi- 
cian to use the laser to seal tears, make tiny openings, 
evaporate small amounts of tissue, and stop bleeding. 

Ophthalmologists use several types of lasers. The color 
associated with each type enables it to target specific tis- 
sues without damaging others. Yttrium aluminum garnet 
(YAG) lasers use infrared rays in the near-visible spectrum 
to treat problems in the front of the eye. The YAG is called 
a photo disruption laser, and it uses rapid, tiny bursts of 
energy to make tiny openings in the eye. Other lasers are 





Figure 4-81. Non-Contact™ II Tonometer. 
{Photo courtesy: Reichert Ophthalmic 
Instruments, Buffalo, NY.) 



Figure 4-82. Tangent screen. (Photo courtesy: Richmond Products.) 



Figure 4-83. Projection 
perimeter. [Photo courtesy: 
Marco Ophthalmic, 
Jacksonville, FL.) 




Ophthalmology 175 




Figure 4-84. Aura™ Nd:YAG ophthalmic laser. [Photo courtesy: 
Coherent Medical Group, Santa Clara, CA.) 



called photocoagulation lasers that use heat (light) to spot- 
weld tears and leaks in the retinal vessels of the eye and to 
produce openings in the iris in the front of the eye. 

A laser room may be as small as 8X8 feet or 10x10 
feet. Ophthalmic lasers come out of a slit-lamp micro- 
scope, which sits on a portable stand. The ophthalmolo- 
gist sits on one side of the table and the patient on the 
other, resting the chin in a support to immobilize the head 



(Figure 4-84). A sink cabinet 6 to 8 feet long is a general 
requirement for any special procedure room, and room 
lights must be able to be dimmed during the procedure. 

As lasers are expensive, some physicians have them in 
their office, while others may do laser procedures in an 
outpatient eye clinic at a nearby hospital. The advantages 
of laser surgery are many: The eye is not opened surgi- 
cally; there is no needle or stitches; and the risk of infec- 
tion is minimal. 

It should be noted that laser use requires the obser- 
vance of safety precautions. The American National 
Standards Institute (ANSI) publishes standards for the 
safe use of laser systems. Specific safety devices and 
warning labels must be used. The eyes are most suscep- 
tible to laser injury. 

Rooms in which lasers are in use must have a warning 
sign posted on the door that reads DANGER — Laser 
Radiation — Avoid Eye or Skin Exposure to Direct or 
Scattered Radiation. When using infrared wavelengths 
such as the YAG, the word "invisible" must be included in 
the warning sign. 

It is important to have nonspecular (nonreflecting) and 
fire-resistant material in or near the beam path. Doors 
may require safety latches or interlocks to prevent unex- 
pected entry into laser-controlled areas. If the door to the 
room has a window, it must have a window shade that 
can be rolled down during laser use. Everyone in the 
room must wear goggles to protect his or her eyes. 
(Goggles are specific to each type of laser that is used.) 

Whereas older argon and some YAG lasers require a 
direct water connection, newer ones do not. The reader is 
referred to Chapter 7 for additional discussion of lasers. 
The Nd:YAG laser pictured in Figure 4-84 is cooled by air 
convection and does not require water, while the multi- 
wavelength laser, used by retinal specialists, has an inter- 
nal water-cooling system. 



Fluorescein Angiography 

Not all ophthalmologists do fluorescein angiograms in 
their offices. Some refer their patients to a retinal sub- 



176 Medicine: Specialized Suites 



specialist or to an outpatient eye clinic associated with a 
nearby hospital. Fluorescein dye is injected into the 
patient's arm. The resulting photographs of the retina 
show if there is leakage of fluids, edema, or poor circula- 
tion. This procedure can be done in a minor treatment or 
special procedure room, and it is performed by a technol- 
ogist, not the physician. 

No special accommodation is required in the room, as 
the patient sits on a standard chair on one side of an 
instrument table, with the tech on the other side. A small 
darkroom should be nearby. A workroom for the tech is 
optional and depends on what other rooms are close at 
hand. A retinal specialist would have a dedicated room for 
angiograms, with an adjacent office for the photographer, 
and a mydriatic or drop room nearby. The entire proce- 
dure, including waiting time for dilation of the pupil, can 
take as long as 45 minutes. 



Office-Based Surgery 

It is a matter of personal preference whether an ophthal- 
mologist chooses to do surgery (nonlaser) within the 
office. Some may elect, for a variety of reasons, to use an 
ambulatory surgical center located in the medical office 
building or one located in a nearby hospital. The advan- 
tages of performing surgery in one's office are conven- 
ience for the patient, convenience in scheduling proce- 
dures, and revenue generated for the medical practice. 
Disadvantages include the initial cost to create a surgery 
facility that meets state licensing and/or Medicare certifi- 
cation criteria, the cost of equipping it, additional cover- 
age, and the risks assumed, however slight, when per- 
forming surgery outside the hospital or ambulatory surgi- 
cal center settings. 

Since eye surgery is generally not elective in nature, a 
physician would want to be certain the office-based sur- 
gery facility meets requirements for reimbursement by 
third-party payers. In fact, the majority of patients needing 
surgery are over 65 years of age, and Medicare reim- 
bursement would be essential to an ophthalmologist's 
practice. 



Removal of cataracts is one of the most common types 
of ophthalmic surgery. It is generally performed using a 
local anesthetic (eyedrops) and is sometimes accompa- 
nied by conscious sedation, administered by a nurse 
anesthetist or an anesthesiologist. This type of surgery is 
performed in a sterile room, which means it's generally 
done in an ambulatory surgical center. An incision is 
made; the clouded lens (cataract) is removed; and an 
intraocular lens (artificial lens) is inserted. The surgical 
portion of the procedure takes 15 to 30 minutes. The 
patient recovers in a recliner chair for about 15 minutes 
before being released to go home. 

Some ophthalmologists do all of their surgery in an 
ambulatory surgical center. Others do only those surger- 
ies requiring general anesthesia in an ambulatory surgi- 
cal center, and procedures done with a local anesthetic 
such as cataract surgery and radial keratotomy are done 
in the office. Some use a room no larger than a standard 
minor treatment or special procedure room, with an adja- 
cent nurse station, small recovery area, and clean utility 
room. When general anesthesia is used, state fire mar- 
shal and Medicare certification requirements become 
strict. Many Life Safety Code regulations must be met. 
The reader is referred to Chapter 7 for a more complete 
discussion of this issue. 

The designer should note that ophthalmic surgery is 
done while looking through a microscope. Therefore, 
vibration can be a problem. If the office is in a medical 
building near a railroad track or close to a major freeway, 
there could be some undesirable vibration, depending on 
the height of the building, the location of the suite within 
the building, and the type of structural system that sup- 
ports the building. 



Laser Eye Surgery 

Photorefractive Keratectomy 

Photorefractive keratectomy (PRK) is a procedure to cor- 
rect mild nearsightedness. In PRK, the surgeon scrapes 
away the outer surface of the cornea and then reshapes 
the underlying tissues with a cool ultraviolet beam. Only 



Ophthalmology 177 



"eyedrop" anesthesia is required. As this procedure may 
result in scar tissue and can correct only mild nearsight- 
edness, it is losing ground to the highly touted LASIK pro- 
cedure. 

LASIK 

LASIK — an acronym for laser in situ keratomileusis — has 
been made possible by the excimer laser (Figure 4-85), 
which reshapes the cornea to correct nearsightedness, far- 
sightedness, and astigmatism. Using an instrument called 
a microkeratome, the surgeon folds back a thin protective 
flap of corneal tissue. The excimer laser then removes a 
predetermined amount of tissue from the inner cornea to 
correct the refractive error. The corneal flap is replaced in 
its original position where it bonds without sutures. 




Figure 4-85. LASIK surgery equipment. {Photo courtesy: Jain Malkin Inc.; Photographer: Don Kohlbauer.) 



So popular is this procedure that a number of ophthal- 
mologists do nothing but LASIK in specialized facilities 
designed for this purpose (Figure 4-86). Taking only 15 
minutes for the entire procedure, it is hugely profitable 
and carries little risk in competent hands. As this is an 
elective procedure, insurance companies do not cover it. 
LASIK surgeons often use multimedia marketing (TV, 
print ads, telemarketing, and Web sites) to drive up 
patient volume and may even resort to customer-pleasing 
gimmicks such as limousine service. Although some 
LASIK specialists may abhor this level of commercialism, 
others unabashedly buy time on local TV stations to cre- 
ate advertorials that depict the surgeon and satisfied 
patients. Because there is great competition among prac- 
titioners, marketing services are a standard part of the 
practice. A waiting room that can double as a seminar 
room in the evening works well. An adjacent storage room 
for folding chairs, a credenza for refreshments, and a 
large screen TV are needed (Figures 4-86 and 4-87). 

Layout of Rooms 

A facility will generally have one procedure room approx- 
imately 12X15 feet, which may be connected to a small 
lab (for sterilizing instruments), two standard pre-op 
refraction rooms, a small topographic room, a small slit- 
lamp room to be used by the surgeon postsurgical^ to 
check the patient prior to discharge, and a small recovery 
room in which the patient spends a few moments in a 
recliner chair while receiving discharge instructions. The 
patient does not change clothes or gown; however, lock- 
ers for handbags, briefcase, and coats are useful. The 
"topo" room has a tabletop autorefractor and a diagnostic 
instrument that measures the curvature of the cornea to 
produce a topographical map of the surface. Both instru- 
ments fit on a 2- x 4-foot table with a stool for the tech on 
one side and a chair for the patient on the other. 

LASIK Room 

HVAC Considerations. Although this is not a sterile 
room, sterile technique is followed. Eyedrop anesthetic is 
used. Control of humidity and temperature is essential for 



178 Medicine: Specialized Suites 




LASER EYE SURGERY 



2400 SF 

Figure 4-86. Space plan for laser eye surgery, 2400 square feet. {Design: William Smith 
Associates, San Diego, CA.) 



Ophthalmology 179 




Figure 4-87. Waiting room, LASIK surgery center. (Interior Design: Jain Malkin Inc.; Photographer: Don Kohlbauer.) 



proper functioning of the equipment and mixing of gases. 
Relative humidity of 35 to 65 and temperature of 60 to 80 
degrees Fahrenheit is the desired range according to 
VIS-X, the leading manufacturer of the Excimer laser. A 
dehumidifier may be required. The surgeon needs to be 
able to adjust the room humidity and temperature to keep 
the machine calibrated. 

The room should have positive pressure to keep the air 
clean and, ideally, a HEPA filter. The HVAC must be sep- 
arate from the rest of the facility to achieve this level of 
control and should be activated by controls within the pro- 
cedure room. In case of a gas leak, the room air must be 
evacuated in two minutes. 

Ideally, the exhaust would be vented to the outdoors 
but, if this is not possible, a room scrubber system can be 



installed to filter the fluorine out of the air. A built-in detec- 
tion system monitors gas leaks. 

Observation Window. An observation window (with a 
blind controlled from the procedure room) that enables a 
family member to watch is a popular feature (Figure 4-86). 

Lighting. There are no special lighting requirements. 
However, there is an advantage to being able to dim the 
lights when using some accessory devices on the 
machine. 

Finishes. Reflectance of walls and floors is not a problem 
as the laser beam is narrowly focused on the eye. A large 
window (glass), whether exterior or interior, depending on 
placement in relation to the machine, can create annoy- 
ing glare. 



Other Considerations 

An ophthalmologist may accumulate 1 1 to 12 lineal feet of 
medical charts in a year, so the file area should accom- 
modate about 48 lineal feet per doctor. Inactive charts 
can be stored in file transfer boxes in the storage room or 
off site. 

The consultation room functions as a private office, a 
place to relax between patients, to read mail, or to make 
phone calls. It is rarely used for consulting with patients; 
thus, it can be small. 



Interior Design 

The interior design of this suite should be cheerful, and 
lighting is of critical importance. The waiting room should 
have good reading light, as many of the patients are eld- 
erly, which means they need a high intensity of light to be 
able to read with comfort. Those with cataracts, however, 
will find glare very uncomfortable. A high level of indirect 
light, supplemented by table lamps, would meet the 
needs of most individuals. 



180 Medicine: Specialized Suites 




Figure 4-90. Reception desk, LASIK surgery center. (Interior Design: Jain Malkin Inc.; Photographer: Don Kohlbauer.) 

In refraction rooms, the designer must be extremely 
careful to select wallcoverings that have absolutely no 
visual rhythm or figure-ground reversal. People who visit 
an ophthalmologist have a variety of vision problems, 
some of which include distortions. A person who sees a 
triple image or one whose vision is blurred might experi- 
ence considerable discomfort in looking at a busy wallpa- 
per or a geometric design. As the lens ages, it thickens 
and yellows. To know how colors might be perceived by 
the elderly, one can look through a pair of yellow lenses. 

The waiting room in Color Plate 15, Figure 4-88, would 
be quite appropriate for an ophthalmologist's office if 
patients are predominantly elderly. Note the design of the 
reception window in Color Plate 16, Figure 4-89, using 
modular furniture systems and the open, welcoming 
reception desk in Figure 4-90. Many educational 
brochures are dispensed in this specialty, necessitating 
brochure racks (Figure 4-91). 




Figure 4-91. Built-in brochure rack. (Design: OSM Architects; 
Photographer: Jain Malkin.) 



Ophthalmology 181 



PLASTIC SURGERY 

Plastic surgery suites vary considerably, depending on 
the focus of the practice (cosmetic or reconstructive) and 
whether there is an intention to provide skin care or spa 
services (a recent trend). Skin care/spa services may 
include microdermabrasion skin resurfacing, chemical 
peels, permanent hair removal by a diode laser, facials, 
body and cellulite treatments, as well as makeup tattoo- 
ing of eyeliner or brows. These procedures are explained 
in greater detail, and room requirements discussed, in the 
Dermatology section of this chapter and at the end of this 
section. 

Another factor that will influence space planning is 
whether the plastic surgeon uses an advertising practice 
model. Some practitioners allocate a significant budget for 
advertising, publicity, or media consultants, and many offer 
educational seminars. As an example, a plastic surgeon in 
a building that contains a sizable breast care center may 
wish to conduct seminars on breast reconstruction for 
mastectomy candidates or may wish to conduct a seminar 
on skin resurfacing techniques. In these practices, the 
waiting room may have to double as a meeting room for 
slide presentations. If the design of the office makes a 
great first impression, it will be more valuable to entice 
prospective patients into the office than to conduct a sem- 
inar off site at a hotel. Plastic surgery is highly competitive 
since most procedures are elective and not reimbursed by 
insurance. Plastic surgeons have great earning power as 
they have been relatively unaffected by the vagaries of 
managed care and they realize that making an investment 
in outstanding interior design can enhance their image. 

A plastic surgeon with a cosmetically oriented practice 
needs to "market" his or her skills and successes. Dentists 
specializing in cosmetic or aesthetic dentistry are in 
somewhat the same situation in terms of being interviewed 
by prospective patients and having to "sell the case." Often, 
people self-refer, based on a successful outcome of a 
friend or relative, but the quest for an idealized self-image 
and the desire to restore one's youthful appearance cause 
many women (83 percent of plastic surgery patients are 
women) to interview a number of plastic surgeons. 



As it is time consuming for the busy surgeon to do 
these initial evaluations, factors that increase the likeli- 
hood of that patient returning to have the procedure are 
worthwhile. This means that the appearance and func- 
tion of the office are important. The prospective patient 
has to make a number of stops during that initial evalua- 
tion and the office should seem orderly and well organ- 
ized. The patient may be greeted by the patient care 
coordinator who will discuss the type of procedure the 
patient has in mind and who may take the patient into a 
private office and allow her to peruse a book of "before 
and after" photos of patients who have had that proce- 
dure. The next stop might be the physician's consultation 
room where the physician will interview the patient, per- 
haps sketch some possibilities, and show slides of 
patients who started out with a similar problem that has 
now been resolved. After the surgeon determines which 
procedures are necessary to accomplish the goal, the 
patient would move to the financial counseling office, or 
patient care coordinator, to discuss fees and payment 
plans and to answer any "process" questions. Ideally, the 
financial counseling office and consultation room would 
be near the front of the suite so that these patients do not 
have to mix with those who have already been scheduled 
for procedures and may be there for the pre-op workup 
or post-op visits. 

Plastic surgeons often do surgery in their offices in a 
properly equipped office-based surgery center, described 
more completely later in this section. Those who don't, 
will do their cases in an ambulatory surgery center, which 
may be available in the medical office building; or a free- 
standing surgery center where they have privileges; or a 
hospital, which is probably the least desirable alternative 
for plastic surgery unless it is so extensive that the patient 
has to stay overnight and receive an intensive level of 
monitoring. It should be mentioned that there are, in some 
cities, 72-hour-stay recovery-care centers which allow 
more complicated cases to be safely handled in an ambu- 
latory surgical setting. 

There are a number of reasons for performing plastic 
surgery on an outpatient basis in the surgeon's office. 
Principally, the patient is more comfortable in a physi- 



182 Medicine: Specialized Suites 



cian's office because it is a less clinical environment than 
a hospital, and it affords more privacy. Patients undergo- 
ing cosmetic procedures are often very concerned about 
bumping into friends and neighbors. It is not uncommon 
for people to visit a plastic surgeon in another city in order 
to safeguard their "secret." 

There are other advantages to surgery outside the hos- 
pital setting. The surgeon has more control over scheduling 
when procedures are done in the office, and the patient 
avoids the generally frightening experience of being admit- 
ted to a hospital. It usually lowers the cost for the patient 
and permits the physician to charge a fee for the use of the 
operating room, rather than lose that fee to the hospital. 

In some plastic surgery practices, approximately 95 
percent of the surgery caseload can be performed in a 
properly equipped operating suite within the office. 
Liposuction has become one of the most commonly per- 
formed procedures for removing unwanted fat from the 



stomach, buttocks, thighs, or other areas. Briefly, in this 
procedure, an incision is made in the skin, a cannula 
(tube) is inserted, and the fat is suctioned out. Other pro- 
cedures commonly performed by plastic surgeons 
include facelifts, breast augmentation (or reduction), 
rhinoplasty (reshaping the nose), hair transplants, hand 
surgery, skin grafts for burn survivors and repair of cleft 
palate (both usually done in a hospital setting), breast 
reconstruction associated with cancer surgery, and other 
disfiguring malformations of the face and head. The top 
three cosmetic procedures in the United States are lipo- 
suction, breast augmentation, and eyelid lifts. 



Circulation Patterns and Patient Flow 

If a plastic surgeon is going to do office-based surgery, 
the optimum flow would be that shown in Figures 4-92, 



PUA^T|£ *l/p<sei*Y 




Figure 4-92. Schematic diagram of a plastic surgery suite. 



Plastic Surgery 183 



Table 4-5. 

Analysis of Program. 

Plastic Surgery 



No. of Physicians: 




1 






2 






(Without Surgery Suite) 


(With Surgery Suite) 


Consultation Rooms 3 




12 X 16 


= 192 


2@ 


12 X16 


= 384 


Exam Rooms 


2@ 


8 X 12 


= 192 


4@ 


8 X12 


= 384 


Minor Treatment 




10 X 12 


= 120 




10 X12 


= 120 


Nurse Station 




8X10 


= 80 




8 X10 


= 80 


Operating Suite* 




— 






— 


1600 


Primary Waiting Room 




16 x 16 


= 256 




16 X18 


= 288 


Surgery and Post-Op Waiting 


10 x 10 


= 100 




10 X12 


= 120 


Business Office 




16 x 20 


= 320 




16 x 24 


= 384 


Financial Counseling 




10 x 12 


= 120 




10 X12 


= 120 


Toilets 


2@ 


7X8 


= 112 


3@ 


7X8 


= 168 


Storage 


2@ 


6X8 


= 96 


2@ 


6X8 


= 96 


Shampoo/Makeup 




— 






12 X12 


= 144 


Spa Services/Skin Care 




20 x 30 


= 600 




— 




Staff Lounge 




12 X 12 


= 144 




12 X12 


= 144 


Subtotal 






2332 ft 2 






4032 ft 2 


20% Circulation 






466 






806 


Total 






2799 ft 2 






4838 ft 2 



a Used both as private office and for consultation with new patients. 

includes (2) ORs, nurse station, scrub, clean and soiled utility rooms, recovery, equipment storage (vac- 
uum, med gases, air, generator), patient toilet/lockers, and male/female staff dressing. 1600 square feet 
is a minimum. 

Note: The above is merely an approximation, since plastic surgery suites can vary considerably in size 
and number of rooms, depending on the physician's scope of procedures and practice philosophy. 



4-93, and 4-94, in which surgical patients are separated 
from the pre-op and post-op examination areas of the 
suite. There are separate waiting rooms, but there is no 
duplication of staff required since the receptionist can 
monitor both rooms, although, ideally, in terms of 
Medicare, even the reception/business office for the sur- 
gery suite should be separate. To comply with Medicare 
certification, there should be complete separation of the 
surgery suite from the office practice during hours of 
operation of the surgery center and it must be a sepa- 
rate business entity maintaining separate records. The 
door to the surgery suite (from the medical office) should 
be able to be secured by means of a keypad to prevent 
unauthorized entry. Few plastic surgeons, however, seek 
Medicare certification; AAAHC accreditation is more 
common. 

The flow through the suite for elective cases would 
begin with the initial consultation and, if the patient 
decides to proceed, would then include one or two pre- 
op visits, the actual surgery, plus multiple post-op vis- 
its. Trauma cases or emergencies would generally be 
seen at the hospital initially with follow-up visits in the 
office. 

The practice documents results with "before" and "after" 
photos of patients. Photographs are an important part of 
the plastic surgery practice. These photos can be taken in 
the examination room (where a pull-down panel of blue 
fabric is mounted to the wall as a background) or in a small 
windowless 6-x8-foot room designed for that purpose 
(Figure 4-95). 

With most procedures, the patient is operated on in the 
morning, spends one or two hours in the recovery room, 
and goes home that afternoon. The doctor's afternoons 
would be spent visiting hospitalized patients, conducting 
consultations in the office with prospective patients, and 
seeing postoperative patients to change dressings or 
remove sutures. If the doctor doesn't have a surgery facil- 
ity in house, the schedule may be arranged as "OR days" 
and "office days," which also accommodates OR staff who 
want to work full days. 



184 Medicine: Specialized Suites 







CONSULT 



r 



nsu^o/ih 



n □ 



U 



PLASTIC SURGERY 



[7 : pc] 



L/ 



4480 SF 



Figure 4-93. Space plan for plastic surgery, 4480 square feet. (Design: Jain Malkin Inc.) 




KJ 



Plastic Surgery 185 




PLASTIC SURGERY 



6190 SF 



Figure 4-94. Space plan for plastic surgery, 6190 square feet. 
(Design: Jain Malkin Inc.) 



186 Medicine: Specialized Suites 



Secluded Entry 

The composition of the plastic surgeon's practice will dic- 
tate the design features that need to be incorporated. A 
practice dedicated to cosmetic surgery may cater to an 
affluent clientele who expect a luxurious office. Of partic- 
ular importance is a secluded entrance so that clients 
may park their cars and conveniently enter the office 
without being seen. After the procedure, they can slip out 
a private exit and elude others in the waiting room. 

For this reason, plastic surgeons who specialize in cos- 
metic surgery frequently prefer a ground floor location, 
with a private driveway or turnaround so that patients 
need not walk through the lobby or public areas of the 
medical building (Figure 4-94). This is valid even when the 
practice is composed of a less affluent population. 
Patients who elect to have cosmetic surgery may be self- 
conscious about it and prefer privacy. It is very important 
to understand the practice's patient base and procedure 
mix. A common design mistake is to tailor it for the wrong 
target market. Today, plastic surgery has a wide middle- 
income base and, depending on the demographics, a 
high-profile design may be intimidating. 



Concierge Reception Desk 

A concierge-type reception desk is often preferred to a 
typical medical office reception window (Color Plate 10, 
Figure 4-22, and Figure 4-96). 



Examination Rooms 

Exam rooms in a plastic surgeon's office are quite differ- 
ent from those in other types of medical offices in that they 
generally use a motorized chair (Figure 4-97), or one room 
might be designed for examining hands (Color Plate 16, 
Figure 4-98). Note that the last example also doubles as a 
recovery room when the bed that stores in the wall is 
pulled down and the table pushed back into the cabinet, 
acting as a bedside table. The room also serves for patient 




PLASTIC SURGERY 



2415 SF 



Figure 4-95. Space plan for plastic surgery, 2415 square feet. (Design: Jain Malkin Inc.) 



Plastic Surgery 187 




Figure 4-96. Reception desk, plastic surgery suite. (Interior design: Kelly Wearstler, Los Angeles, CA; 
Photo courtesy: Grey Crawford©.) 



Figure 4-97. Examination room, plastic surgery suite. (Design: Jain Malkin Inc.; 
Photographer: Michael Denny.) 



188 Medicine: Specialized Suites 



education, with a built-in VCR and TV monitor. Plastic sur- 
gery exam rooms may be large and elegantly designed, 
especially if used as the consultation room as well (Color 
Plate 17, Figures 4-99a and 4-99b). A clever treatment for 
the end of the exam room corridor (Figure 4-100) uses a 
mirror to give the illusion of an open-shelved divider with 
corridors on both sides. A different type of illusion is creat- 
ed by the trompe I'oeil mural at the end of the exam corri- 
dor in Color Plate 18, Figure 4-101, en route to the surgi- 
cal suite in Figure 4-102. In this same suite, high ceilings 
make possible a geometry of intersecting planes comple- 
mented by cable lights that dance through clerestory 
openings (Color Plate 18, Figure 4-103). 



Consultation Room 

Patients considering surgery often interview more than 
one physician who may spend half an hour or more with 
a patient showing slides or photos of other patients who 
have had similar procedures, reviewing costs, and dis- 
cussing the probable outcome. This initial consultation is 
an important element of a plastic surgeon's practice, 
because it is generally just this one meeting by which the 
patient decides whether he or she is comfortable with the 
surgeon's personality, qualifications, and results. 

Plastic surgeons often use their private offices (consul- 
tation rooms) to make case presentations (Color Plate 17, 
Figure 4-99c), or a special room may be designed for this 
purpose (Figures 4-95 and 4-102). It is desirable to func- 
tionally and visually integrate the audiovisual (AV) pres- 
entation equipment (monitor, slide projector, or digital 
projector) into a custom-built wrap-around desk from 
which all elements, including dimming of room lights, can 
be controlled. New technology with digital photography 
means more surgeons will use presentation software. 
Monitor placement must consider this possibility. The new 
trend is multiple monitors displaying "before and after" 
photos located in exam rooms or wherever the surgeon 
prefers to do initial interviews/consults. Networked soft- 
ware allows photos to be accessed wherever there is a 
computer and monitor. 




Figure 4-100. Clever treatment at end of corridor in plastic surgery suite uses a mirror to create the 
illusion of additional space. (Interior design: Kelly Wearstler, Los Angeles, CA; Photo courtesy: Grey 
Crawford©.) 



Plastic Surgery 189 




■ BIO HAZARD 



PLASTIC SURGERY 



3355 SF 



Figure 4-102. Space plan for plastic surgery, 3355 square feet. (Design: Jain Malkin Inc.) 



190 Medicine: Specialized Suites 



Some physicians use a computer photoimaging sys- 
tem to demonstrate to patients possible outcomes from 
surgery. If this is to be used, the designer must plan well 
to accommodate it as the equipment, as well as the posi- 
tion of the patient and camera, require a certain relation- 
ship, specific countertop heights, and space allocation; 
otherwise, the process can be exasperating. This is often 
located in a small room, rather than in the physician's pri- 
vate office/consultation room. 

The consultation room should convey a solid, success- 
ful image, but not be flamboyant or trendy. This room 
might be styled more conservatively than the remainder 
of the suite, although this is determined in large part by 
what would be appropriate for the patient population 
served. A plastic surgeon in Beverly Hills, to be competi- 
tive, would probably have a more lavishly designed office 
than one in Des Moines, Iowa. The space should be 
designed with the female consumer in mind although it 
should be noted that some plastic surgeons have per- 
fected a specific procedure for men that brings them a 
higher number of male patients than the average. 

The surgeon's diplomas and awards should be promi- 
nently displayed here in elegant frames and mats. 
Sometimes patient education is accommodated in the 
consultation room (a VCR and TV would be provided), or 
a dedicated room is created for this purpose. 



Office-Based Surgery 

Surgery performed within the physician's office is called 
office-based surgery, compared with that which is per- 
formed in a freestanding ambulatory surgical center. The 
latter is called freestanding, because it is not attached to 
or associated with a physician's office and is physically 
separate from a hospital. The reader is referred to 
Chapter 7 for additional information. 

Any discussion of office-based surgery begins with the 
issue of reimbursement. Unlike surgery performed by oph- 
thalmologists, most plastic surgery is elective in nature 
and, as such, would not be covered by third-party payers. 
Therefore, designing the surgery suite to meet the criteria 



for reimbursement by third-party payers seems a moot 
point. Those cases that would be reimbursed (for example, 
reconstructive surgery to attach a severed finger or surgery 
to restore a burn victim's appearance) would be done out- 
side the office in an ambulatory surgical center or hospital. 
Most insurance companies and Medicare will pay the 
physician's fee for any covered procedures done in the 
physician's office, but if the surgery suite itself does not 
meet certain requirements, they will not reimburse for the 
use of the facility. 

Accreditation, Licensing, 
and Medicare Certification 

Major changes have recently occurred with respect to 
enhancing patient safety in the office-based surgery set- 
ting. While there are many differences among individual 
states, from the national perspective, the American 
Society of Plastic Surgeons and the American Society for 
Aesthetic Plastic Surgery mandated January 1, 2002 
compliance for their members to operate in facilities that 
are accredited by one of the national accreditation organ- 
izations, or be Medicare certified (even a more rigorous 
standard), or be state licensed, also quite stringent. 

What triggers compliance with NFPA fire codes is 
whether more than four persons are incapable of self- 
preservation at one time. If not, meeting occupancy 
codes will generally suffice. As most plastic surgeons 
(according to AAAASF) have only one operating room, it 
is unlikely that four or more persons would be in that con- 
dition. But this is certainly a gray area and open to inter- 
pretation. Common sense dictates that even one patient 
deserves the maximum in safety and protection, espe- 
cially if you are that one person. But this explains why, for 
many years, plastic surgeons in some states have been 
able to get occupancy permits for undersized surgery 
suites that fall short, according to many criteria, of what 
would be expected today. 

For those to whom this may be new, states license hos- 
pitals and all types of hospital-based surgery facilities, 
imposing what are generally regarded as the highest or 
most rigorous standards in terms of patient safety, mini- 
mum sizes of rooms, and a host of other issues. Most 



Plastic Surgery 191 



facilities that are state licensed will also have achieved 
Medicare certification. Medicare is a program under 
HCFA (Healthcare Financing Administration). Medicare 
uses NFPA 101 (Life Safety Code) and a local fire mar- 
shal — and sometimes an additional inspector who may 
be a retired surgeon — to inspect for compliance. With 
either licensing or Medicare certification, a fee for the use 
of the facility may be billed. Of the national accreditation 
associations, the AAAASF (American Association for 
Accreditation of Ambulatory Surgery Facilities), located in 
Mundelein, Illinois, considers itself to have the most rig- 
orous standards with very tough quality assurance and, 
according to the director, is the only organization that 
requires semiannual peer review. The AAAASF accredits 
facilities for all surgical specialties as listed by the Board 
of Medical Specialties, including OB-GYN, urology, oph- 
thalmology, ENT, plastic surgery, and orthopedics. It 
should be noted that AAAASF excludes dermatology 
because it is not listed as a surgical specialty. Nor will it 
accredit endoscopy facilities, but AAAHC (Accreditation 
Association for Ambulatory Healthcare) will. 

It is not possible to print a definitive guide to negotiating 
the minefields of accreditation, certification, or licensing 
because one will encounter codes that are contradictory, 
gray areas that are ambiguous, and local inspectors 
whose personal experience leads them to make demands 
that are not stipulated in the code manuals, yet they are in 
a position to deny certification if their requests are not sat- 
isfied. All of this is nasty business for the designer or archi- 
tect who wants to turn over a successful project and meet 
the client's expectations. To add complexity to these mat- 
ters, one agency might use a different version of the code 
than another. Medicare might require the 1985 NFPA and 
this is what AAAASF uses, as of this writing; however, the 
latter anticipates going to the 1997 version, according to a 
discussion (April 2001) with an official at that organization. 
In the 1985 edition, back-up emergency power might be 
battery operated or use a generator. However, the 1997 
edition provides for a generator only with no grandfather- 
ing of what was formerly acceptable. 

The state of Nevada, on the other hand, requires, as 
of this writing, the 1999 NFPA code. In general, where 



there is a discrepancy, the more stringent code applies. 
Some states require a CON (Certificate of Need) for 
Medicare certification, whereas other states require 
state licensing as a precursor to Medicare certification, 
and some states don't require either of these. In 
California, dermatologists must be accredited in order to 
do surgery. AAAASF does not preempt local or federal 
codes and the facility must always be in compliance with 
OSHA. AAAASF requests written documentation to 
prove that the physician has "like" privileges at a local 
hospital to do the kinds of procedures that will be per- 
formed in the office-based setting. 

As a general statement, according to the executive 
director, AAAASF prefers not to give minimum sizes of 
rooms or be draconian in terms of facility design, but 
rather to be flexible in order to allow the physician to meet 
the objective of safety in a variety of ways. This is what it 
means by "adequate" when it states that "a separate and 
adequate recovery room must be maintained free and 
clear of litter." AAAASF specifes that there must be 4 feet 
of open space around all sides of the OR table for patient 
safety during resuscitation. This is stated as, "needs suf- 
ficient space around OR table for emergency personnel 
to get access to the patient." Separate clean and soiled 
rooms are required, without giving sizes. Instead, it might 
read, "instrument prep and assembly area must be sepa- 
rated by a wall from the space where instrument cleaning 
is done or, if not, a policy to disinfect the area each time 
must be in place." Corridor widths are required to be 
"adequate" for movement of gurneys. 

The standards imposed by these various agencies with 
respect to facility design and architectural issues are 
accompanied by standards and protocols for processing of 
tissue samples, peer review, number of kits of Dantrolene 
on hand for malignant hypothermia (general anesthesia is 
the triggering agent), all issues that have nothing whatso- 
ever to do with design but protect patient safety. 

The reader is referred to Chapter 7 for additional dis- 
cussion about accreditation and, specifically, the 
Accreditation Association for Ambulatory Healthcare 
(AAAHC). However, as a closing thought about accredita- 
tion possibilities for office-based practices, state medical 



192 Medicine: Specialized Suites 



licensing boards (licensing of physicians) can often rec- 
ommend state accreditation agencies, which may have 
less rigorous standards with regard to facility design. 

American Association for Accreditation of 
Ambulatory Surgery Facilities 

The American Association for Accreditation of 
Ambulatory Surgery Facilities publishes three booklets 
that will guide both the designer and the facility's staff if 
they wish to meet the voluntary accreditation standards of 
this organization. One booklet is the Inspector's Manual, 
another is the Standards Manual, and the third is the 
Checklist/Questionnaire. 

The major determinant of design criteria relates to the 
type of anesthesia used. This, in turn, relates to the types 
of procedures that can safely be done in the office. The 
AAAASF standards classifications used in the manual 
are as follows: 

Class A — performed under local or topical anesthesia; 
applies to minor plastic surgical procedures. 

Class B — performed under intravenous or parenteral 
sedation, regional anesthesia, analgesia, or dissocia- 
tive drugs without the use of endotracheal or laryngeal 
mask intubation or inhalation general anesthesia, 
including nitrous oxide. 

Class C — performed under general anesthesia with 
endotracheal mask intubation or inhalation anesthesia 
(includes nitrous oxide); external support of vital body 
functions. 

The AAAASF standards cover the environment of the 
surgery facility, general safety, medical records, quality 
assessment and improvement, policies and procedures 
for the OR and recovery room, blood and medications, 
personnel, and governance. An on-site inspection of the 
facility is made the first year, followed by self-evaluation 
the second and third years, and another on-site inspec- 
tion the fourth year. 



Although accreditation by AAAASF is voluntary, it does 
certify to the medical community and the community at 
large that the surgery facility meets nationally recognized 
standards such as those set for members of the American 
Board of Plastic Surgery. The AAAASF recommendations 
are not considered codes, but they are guidelines (stan- 
dard of care issues) for the safe handling of patients. 



Operating Suite Design 

After a thorough discussion with the physician about goals 
for certification, accreditation, and/or licensing, appropri- 
ate code references must be consulted. The reader is 
referred to Chapter 7 for a discussion of these issues. 

The minimum size of an operating room, in terms of 
function, number of personnel, and equipment (based on 
doing Class A procedures), is 14x16 feet clear, which 
may include one full wall of built-in cabinets for supplies. 
Outside the room, provide a scrub sink; storage for linens, 
gowns, caps, disposable supplies, and surgical dress- 
ings; drawers or carts for sterilized surgical instruments; 
clean and soiled utility rooms; a sterilization area; and 
male and female staff dressing area with lockers if space 
permits. Note that ORs may not have sinks in them as this 
compromises infection control. 

Utility Areas 

One often finds, in plastic surgery offices, attempts to 
save space by combining rooms like clean and soiled into 
a common "prep" area. It may even open off of the oper- 
ating room as in Figure 4-95. Note in this plan that the 
scrub is alongside the nurse station and the latter is a 
"galley" nurse station against a wall. This is typical of 
many office-based facilities that try to cram two pounds of 
program into a one-pound space. In Figure 4-102, the 
soiled utility is quite small and recovery beds are under- 
sized. Space is tight throughout the surgery suite. In the 
latter case, the surgeon found the "perfect" location, a 
high-profile freestanding building, with the ideal address, 
but the suite was locked in on all sides with no additional 
space to be acquired. To be functional, and meet busi- 



Plastic Surgery 193 



ness plan objectives, no rooms could be eliminated. High 
ceilings, however, allowed for dramatic interior design 
(Color Plate 18, Figures 4-101 and 4-103). Full-height 
maple doors have wood transoms and custom flush door 
jambs to direct the eye to the ceiling treatments. 

As regulations tighten, the common "prep" room will be 
replaced by separate soiled and clean utility rooms as in 
Figures 4-93 and 4-94. However, if a common prep room 
is indicated, it should be designed similarly to a large 
nurse station. It should be a minimum of 1 0x 1 2 feet, lined 
with cabinets and work surfaces. Instruments will be ster- 
ilized and wrapped here; dressings and medications are 
prepared. Do not underestimate the amount of space 
required for sterilizers and work space and also a rather 
sizable piece of equipment, a blanket warmer. Clinic serv- 
ice sinks and standard sinks in the prep or cleanup area 
should have plaster traps. 

Falling in Love with a Space That's Too Small 

One may note considerable variation in these space plans 
with respect to the composition of the operating room 
suite. Typically, a plastic surgeon finds an "ideal" lease 
space in terms of location, views, the "right" building, and it 
invariably has less space than required to design an opti- 
mum operating room suite. If the surgeon does not intend 
to seek accreditation to be able to bill a facility use fee, and 
does not intend to allow other "outside" surgeons to use 
the facility, there is considerable leeway in terms of mini- 
mum sizes of rooms, minimum sizes of recovery bays, 
separation of clean and soiled, and numerous other fac- 
tors that are highly controlled in state-licensed facilities 
and those accredited by Medicare. Refer to Chapters 7 
and 15 for more specific information on codes. 

Occasionally, a surgeon may request a large OR with 
two tables and only a cubicle drape separating them, but 
regulatory agencies do not allow this due to risk of cross- 
contamination and also lack of privacy. In a busy practice, 
while the nurse is prepping one patient, the surgeon may 
be completing surgery on another, and a nurse may be 
applying a dressing on the third before moving the patient 
to a nearby recovery room. On this basis, three operating 
tables could be in use simultaneously, sometimes even 



with just one plastic surgeon working, but it would be very 
expensive, in terms of space, to build three ORs in a one- 
physician practice. Some plastic surgeons design a large 
operating room that is divided into two separate rooms by 
a wide cabinet that can be accessed from either side but 
this is no longer allowed. 

Design of the OR 

An OR will have a motorized operating table and ceiling- 
mounted surgical lights (which require support above the 
ceiling) overhead. A crash cart containing resuscitation 
equipment and a defibrillator (Figure 3-55) must be in the 
room as well as an anesthesia machine. Oxygen and suc- 
tion (vacuum) can be either piped into the room or 
portable, but most plastic surgeons would want central 
(not portable) medical gases. Some prefer that they be 
piped through the ceiling to keep cords off of the floor 
(Figure 4-104). The designer must check local fire code 
requirements for storage of anesthetic gases. (See 
Chapters 7 and 14 for additional discussion.) 

If Class B and Class C anesthetic procedures are to be 
done, there will be a number of pieces of monitoring equip- 
ment, plus the anesthesia machine, in the room. There will 
also be an anesthesiologist or nurse anesthetist, one or two 
nurses, and the physician. This is the reason that operating 
rooms are often 1 6x 1 8 feet or 1 8x 1 8 feet in size. Access to 
supplies within the OR is necessary. Often, a full wall (full 
height) of 15-inch-deep cabinets with adjustable shelves 
and glass doors is either recessed into the wall or, if not, 
designed with a sloped top to avoid collecting dust. Prefab 
metal cabinets specifically for ORs are available or they can 
be custom plastic laminate casework. 

Lasers are often used in plastic surgery. Refer to a dis- 
cussion, and photos of lasers, in the Dermatology and 
Ophthalmology sections of this chapter and in Chapter 7. 

Interior Finishes 

The operating room must be easy to clean. Walls should 
have an eggshell enamel paint finish. This does not pre- 
clude, however, having an artist stencil or paint a decora- 
tive border around the room to make it less intimidating to 
patients. A floor with a minimum of joints is desirable — a 



194 Medicine: Specialized Suites 



hospital-quality sheet vinyl with self-coved base and heat- 
welded seams. Refer to Chapter 12 for recommendations. 

Access by Vendors 

A lot of linen is used in a surgery facility, and accommo- 
dation must be made for large carts of soiled linen and 
storage of clean linen. It is ideal if the linen supply com- 
pany can enter the soiled workroom directly, pick up the 
dirty linen, and drop off the clean (Figures 4-93 and 4-94). 
Similarly, vendors picking up biohazardous waste or 
delivering medical gas cylinders should be able to do this 
without walking through the surgery suite. 

Emergency Power 

An essential element is the emergency back-up power sys- 
tem. Some states and localities, as well as accreditation 
bodies, allow a battery-powered source but the trend is to 
require a generator. There are very specific requirements 
as to the capacity of the generator and the number of items 
that must be tied to it as well as the number of hours it must 
be able to function in an emergency. Obviously, all of this 
relates to the number of ORs, recovery beds, type of anes- 
thesia used, and average length of procedures. 



Dressing Area/Recovery Room 

A dressing room, with lockers for valuables, may be pro- 
vided for patients. This is a moot point, however, since 
patients are told not to bring valuables and must have 
someone drive them home. Often, one's clothing and 
shoes are placed in a basket on the lower portion of the 
gurney, which travels with the patient, both eventually 
ending up in the recovery room. Sometimes the dressing 
area is combined with the recovery room. The recovery 
area should be located immediately adjacent to the oper- 
ating room and nurse station so that staff can keep a 
watchful eye on the recovering patient (Figures 4-93, 4- 
94, and 4-102). Each recovery bed must have suction, 
oxygen, and electronic monitoring equipment. 

Typically, recovery beds are wheeled transport gurneys 
(often called Stryker carts), 2X6 feet. A patient would be 




Figure 4-104. Plastic surgery operating room. {Interior design: Kelly Wearstler, Los Angeles, CA; Photo courtesy: 
Grey Crawford©.) 



moved off the operating table onto a gurney and wheeled 
into the recovery room, so room layouts must allow for 
easy maneuvering of gurney carts without bumping into 
walls. One must be certain that all turns can be navigated. 



Other Considerations 

A busy plastic surgeon who specializes in cosmetic pro- 
cedures may wish to have separate waiting rooms for 
male and female patients. A hairstylist may be on hand 



Plastic Surgery 195 



44-0" 




Figure 4-105. Space plan for plas- 
tic surgery with skin care services 
suite, 3344 square feet. (Design: 
Jain Malkin Inc.) 



PLASTIC SURGERY 



3344 SF 



several afternoons a week to shampoo and style the hair 
of patients who have just had bandages removed after a 
facelift. Patients recovering from facelifts will have dried 
blood and scabs on their scalps, or even staples, which 
can make some hairstylists squeamish. Such patients 
may, understandably, be timid about visiting their own 
stylist in public until the bruises subside. 

A small room should be set aside for this purpose with 
a standard beautician's shampoo chair, professional hair 
dryer, and good-quality mirrors (Figures 4-94 and 4-95). 
A gray-tinted mirror will downplay bruises, yet still provide 
enough reflection. Attractive wallpaper and accessories 
will help lift the patient's spirits. The color of the room 
should be complimentary to skin tones. 

A plastic surgeon may also offer the services of a pro- 
fessional makeup artist for patients recovering from facial 
plastic surgery. This could be done in the same room as 
hairstyling (Figures 4-94 and 4-95). 

Plastic surgeons who specialize more in reconstructive 
surgery — skin grafts for burn victims, surgery of the 
hand, repair of cleft palate, trauma — may not have strong 
sentiments about providing privacy and anonymity for 
their patients, and they may be less interested in the 
appearance or image of their offices. 

Skin Care/Spa Services 

Whether a plastic surgeon does or does not have a sur- 
gery center associated with the office, he or she may wish 
to have a suite of rooms that can be used for skin care or 
spa services. This requires at least two rooms 10x12 feet; 
an 8- x 10-foot room with a sink for prep, storage of clean 
linen, and a hamper for soiled; a reception area with three 
or four chairs; and display cases for cosmetics and pri- 
vate-label skin care products that are available for sale. A 
laundry facility is useful if it can be located so that the 
noise of the washer and dryer cannot be overheard in the 
treatment rooms. These rooms, plus circulation space and 
a restroom, will total approximately 500 square feet, 
which, if not professionally managed, can result in a loss 
rather than profit when compared to the additional rent for 
the space. In many cities, spas have sprung up on every 
block, which means there is a lot of competition. However, 



196 Medicine: Specialized Suites 



10'-0" 




<N 



^ 



12'-0" 



EQ. 



EQ. 



> 



EQ. EQ. EQ.\ EQ. EQ. EQ 



ELEVATION 



- SOILED 
LINEN 
HAMPER 



DUAL-USE EXAM ROOM 
AND SKIN CARE 



Figure 4-106. Dual-use examination room that can also be used for skin care. 
Elevation shows design of casework wall accommodating both usages. {Design: 
Jain Malkin Inc.) 



a busy plastic surgery practice can generate many refer- 
rals with patients having a higher level of confidence 
about the efficacy of the procedures than they might 
have in a commercial setting not associated with a 
physician's office. The ambience of a spa or skin care 
salon is very important. Color, music, fragrance, burning 
candles, and an environment that appears clean and 
bright, with exquisite lighting that flatters skin tones and 
highlights products to be sold, optimize the experience 
for patrons and increase sales. Treatment rooms should 
have soft lighting and feel soothing. Figure 4-105 shows 



a spa services suite associated with a plastic surgery 
office. 

It should be noted that one can design a dual-use 
exam room that will also work for skin care services, opti- 
mizing use of the room even when the physician is out of 
the office. The room must be 10x12 feet, larger than the 
standard exam room and have a full wall of cabinets in 
the long dimension. This results in a 6-foot-wide base 
cabinet with sink and upper cabinet and a 6-foot-wide full- 
height cabinet with three tall doors that conceal equip- 
ment and provide linen storage (Figure 4-106). 



Plastic Surgery 197 



Interior Design 

Since this is a low-volume medical practice, ease of main- 
tenance and durability in finishes and furnishings are 
generally not an issue outside the surgery suite. Materials 
used may be residential in character (Color Plates 17 and 
18, Figures 4-99a-d, and 4-101 and 4-103, respectively). 
The plastic surgeon trades in the quest for an aesthetic 
ideal and the eternal fountain of youth. The office is an 
expression of his or her attention to detail and an indica- 
tion of aesthetic awareness; the image the surgeon proj- 
ects is very important. People want to deal with a surgeon 
who appears to be successful — this amounts to third- 
party endorsement of the plastic surgeon's skills. 

The plastic surgeon who spends a considerable sum 
on office design and furnishings will generally reap the 
rewards. No medical specialty benefits more from a high- 
profile image. Even the plastic surgeon's letterhead and 
business card, as well as brochures, should be striking 
and imaginative and coordinated with the office design. 

All rooms of this suite may be carpeted, exceptforthe sur- 
gery suite and a treatment room for small in-office proce- 
dures. Office design should be stylish but comfortable, and 
lighting should be soft and flattering in all rooms, except the 
exam rooms and operating suite. Incandescent and halogen 
lighting, as well as table lamps, are preferable to fluorescent 
in the waiting room (Color Plate 1 7, Figure 4-99d), corridors, 
and consultation room. The waiting room especially benefits 
from a low level of illumination to mask bruises resulting 
from surgery and to keep patients out of the spotlight. 

The color temperature of fluorescent lamps is critical in 
examination and consultation rooms. A color temperature 
of 3500 kelvins with a high CRI (85 or more) is desirable. 
Consult Chapter 13 for more detail on lighting. 

Bathroom design is important in this specialty. Large 
gray-tinted mirrors and interesting lighting may be incor- 
porated into the vanity cabinet. Walls and ceiling may 
have an attractive wallcovering, and bathroom acces- 
sories (tissue boxes, paper towelette holders, soap dish- 
es) should be elegant and residential in character. Other 
items a patient might use in light grooming before or after 
medical consultation ought to be provided. Grab bars, 



required by the ADA, should not be aluminum — highly 
institutional — and cold to the touch. Those by HEWI, 
which are nylon and can be matched to blend into the 
wall, are preferable. 

Today, many people consider having plastic surgery to 
correct physical imperfections. Taboos about vanity have 
all but disappeared, and society places greater emphasis 
on self-expression, personal fulfillment, and an internal 
state of well-being. There is an increased exposure to the 
benefits of plastic surgery in the media, which has given 
more people the confidence to obtain treatment. Plastic 
surgery is no longer just an option of the rich; many per- 
sons of modest income also consider it a viable option, as 
do an increasing number of men. 



DERMATOLOGY 

A dermatologist treats diseases of the skin. It is not 
uncommon to find a one-physician practice. Since der- 
matologists rarely make hospital rounds or emergency 
house calls, their appointment schedule is strictly 
adhered to without the sort of interruption that plagues 
many other physicians. A one-physician suite would be 
composed of three examination or treatment rooms, a 
waiting room to accommodate eight to ten persons, a 
small lab, a toilet room, a business office, a consultation 
room, a minor surgery, and a large storage closet for drug 
samples (Figure 4-107). Larger practices may include a 
surgery facility, as well as offer ancillary services such as 
laser hair removal, chemical peels, facials, Botox (botu- 
linum toxin) injections, sclerotherapy, Endermologie®, and 
massage. The reader is referred to Chapter 6 for a decen- 
tralized plan of a group-practice dermatology suite and to 
Figure 4-108 for a centralized plan. Figure 4-109 shows 
the relationship of rooms. 



Procedures 

The procedures performed in a dermatology office vary 
widely, depending on the number of providers, their entre- 



198 Medicine: Specialized Suites 



44-0" 




DERMATOLOGY 



1408 SF 
Figure 4-107. Space plan for dermatology, 1408 square feet. (Design: Jain Malkin Inc.) 



preneurial inclinations, and their training. Those having a 
more cosmetically oriented practice may do a consider- 
able amount of plastic and cosmetic surgery and would 
need an office-based surgery facility similar to that used 
by plastic surgeons (see the Plastic Surgery section for 
details). The types of procedures would include brow lifts, 
liposuction, and facelifts. 

Perhaps one of the physicians in a group practice may 
have been trained to do Mohs' surgery (more fully 
explained later in this section) for skin cancer. One of the 



physicians may be known for sclerotherapy techniques 
(treatment of varicose and spider veins) or perhaps hair 
transplantation. 

Dermatologists, especially those with a cosmetically 
oriented practice, use many different types of lasers to 
remove unwanted hair, to do facial peels, and to remove 
tattoos, port-wine stains, birthmarks, red or brown spots, 
and freckles. 

The more entrepreneurial practitioners sell skin care 
products, employ a number of estheticians or cosmetolo- 



Dermatology 199 




=cr 



m^i/wim^ifwi^m 



EXAM #1 



CD CD 



EXAM #2 



□ 



EXAM #3 



CD 



EXAM #4 



CD 



EXAM #5 



CONSULT 



xD 



DERMATOLOGY (off-site business office) 

4735 SF 
Figure 4-108. Space plan for dermatology with off-site business office, 4735 square feet. (Design: Jain Malkin Inc.) 



200 Medicine: Specialized Suites 



t?£g.MAT^U>£Y. 




r path. \f 
I &»- T 

f mogye A. _ 



Figure 4-109. Schematic diagram of a dermatology suite. 



gists to do facials, acne therapy, massage, cellulite thera- 
py, facial chemical peels, and may even have a satellite 
suite for spa services (Figure 4-110). It is easy for a busy 
practice to generate many skin care referrals, and since 
most of these treatments require multiple visits, the vol- 
ume of patients is steady and the profit can bolster sag- 
ging reimbursement for the clinical dermatology practice. 
Each state regulates the types of procedures estheticians 
can do under their licenses; some practices employ a reg- 
istered nurse to oversee this type of enterprise. 

Explanation of Procedures 

Hair Restoration. Accomplished by laser micrografts, 
transplanting hair from one area of the scalp to another. 

Sclerotherapy. Can involve injections into affected spi- 
der veins; removal of veins through small incisions 
(performed under local anesthesia); or "stripping" of 
larger vessels, a more involved procedure requiring 
general anesthesia or conscious sedation plus a local 
anesthetic. 




DERMATOLOGY ESTHETICIAN'S SUITE 

1126 SF 

Figure 4-110. Space plan for dermatology esthetician's services. (Design: Jain Malkin Inc.) 



Dermatology 201 







Table 4-6. 










Analysis of Program. 












Dermatology 








No. of Physicians: 




1 






2 




Exam Rooms 


3@ 


8X10 


= 240 


6@ 


8X10 


= 480 


Minor Surgery 




12 X 12 


= 144 




12 X12 


= 144 


Toilets 


2@ 


7X8 


= 112 


2@ 


7X8 


= 112 


Business Office 




12 X 16 


= 192 




16 X18 


= 288 


Staff Lounge 




10 X 12 


= 120 




10 X12 


= 120 


Waiting Room 




12 X 16 


= 192 




14 X18 


= 252 


Consultation Rooms 




12 X 12 


= 144 


2@ 


12 X12 


= 288 


Lab/Nurse 




8X10 


= 80 




10 X10 


= 100 


Facials/Chemical Peels 




— 






10 X10 


= 100 


Storage 




6X8 


= 48 




6X8 


= 48 


Subtotal 






1272 ft 2 






1932 ft 2 


20% Circulation 






254 






386 


Total 






1526 ft 2 






2318 ft 2 



Botox Injections. A form of botulinum toxin is used to 
smooth out and soften wrinkle lines. It causes tempo- 
rary paralysis of the muscles so that they are unable to 
contract. An injection lasts several months. 

DermaPeel. A skin resurfacing technique using micro- 
scopically abrasive crystals under highly controlled 
pressure to gently remove damaged cells from the 
outer layer of the skin. 

Chemical Peel. A blend of retinoic acid and alphahy- 
droxy acids to smooth the skin. 

Cellulite Therapy. The newest technique is called 
Endermologie® and uses a device patented by LPG 
Systems (Figure 4-111). It requires a 10-x 12-foot 
room as there is a corner photographic station (for 
before and after photos), a hydraulic lift massage table, 
and a large machine. 

Tumescent Liposculpture. Localized fat deposits are 
removed by a high-pressure vacuum through tiny inci- 
sions through which a small cannula (hollow "tube") is 
inserted. Liposculpture uses a smaller cannula than 





Figure 4-111. Endermologie 8 
courtesy: LPG® USA.) 



unit designed to reduce cellulite. (Photo 



liposuction and is performed with local anesthesia with 
oral and/or conscious sedation, rather than general 
anesthesia. These procedures are done in a surgery 
room with resuscitation equipment on hand. 

Laser Surgery. Laser stands for Light Amplification by 
the Stimulated Emission of Radiation. The laser beam 
can cut, seal, or vaporize skin tissue and blood vessels. 
Lasers produce one specific wavelength (color) of light, 



202 Medicine: Specialized Suites 



which has variable intensity and pulse duration. When 
the laser light hits skin tissue, its light energy is 
absorbed by water or pigments in the skin, all of which 
absorb laser light of different wavelengths. A variety of 
lasers are used in dermatology because they are high- 
ly specific: The pulse of light that will vaporize a black 
tattoo will not affect red pigmented spider veins, for 
example. 



Examination Room 

Exam rooms can be 8x10 feet instead of the standard 
8X12 feet. The exam table used is often a flat physical 
therapy table, 24 inches widex78 inches longx36 inches 
high, which may be placed against the wall. When placing 
the table in this room, the head of the table should be 
positioned so that the physician can work on the patient's 
right side. Natural light (a window) is important in derma- 
tology exam rooms. The room should have a sink cabinet 
and perhaps a dressing area, as well as a high level of 
illumination, free of shadows, supplied by full-spectrum 
fluorescent lamps. Adequate lighting is essential in all 
exam rooms. 

One exam room may have a Dermascope (Figure 
4-112), a diagnostic videoscope for examining the skin sur- 
face microscopically. It provides a printed photo for the 
patient and also digitally downloads the information onto 
an electronic medical record or transmits the image, pro- 
vided broadband cable is available, to a remote location for 
a real-time consultation. The unit does not require a dedi- 
cated circuit but does need to plug into a surge suppressor. 



Lab 

The lab will have a microscope and an autoclave for 
cleaning instruments. In a small office, the nurse station 
may be combined with the lab (Figures 4-107 and 4-113). 
In a large suite (Figure 4-108), the pathology lab serves 
the Mohs' surgery area, and decentralized nurse stations 
are adjacent to exam rooms, surgery, and recovery. 




Figure 4-112. Video diagnostic Dermascope enables patient or family 
member to see what the physician sees and facilitates telemedicine 
consultation. {Photo courtesy: AMD Telemedicine, Lowell, MA.) 



Surgical Procedures 

The minor surgery room is 12x12 feet, with a long sink 
cabinet along one wall. Medical equipment to be accom- 
modated in this room would depend on the scope of the 
procedures. However, the equipment would include an 
operating table or chair that adjusts to different positions 
(Figure 4-114) and a ceiling-mounted surgical light over 
the table. If an office-based surgery suite is required, con- 
sult the Plastic Surgery section of this chapter. 

Dermatologists perform many surgical procedures in 
the office. Surgery may be done to improve the skin's 
appearance, to biopsy tissue to establish a diagnosis, or 
to prevent or control disease. Different types of surgical 
procedures include: 

Curettage — scraping the tissue with a sharp surgical 
instrument called a curette. 

Excision — cutting into the skin surgically, removing the 
tumor or growth, then closing the wound with stitches. 

Cryosurgery — using liquid nitrogen sprayed on the tis- 
sue to freeze it and thereby destroy the unwanted cells. 



Dermatology 203 



66-0" 




Figure 4-113. Space plan for dermatol- 
ogy, 2112 square feet. {Design: Jain 
Malkin Inc.) 



DERMATOLOGY 



2112 SF 



Figure 4-114. Minor surgery room, dermatology. 
{Architecture/interiors: Richard Deno, Cardiff, CA; 
Photographer: Kim Brun.) 




204 Medicine: Specialized Suites 





Figure 4-115. UltraPulse® 5000C aesthetic C0 2 laser system for der- 
matology. {Photo courtesy: Coherent Medical Group, Santa Clara, CA.) 



Figure 4-116. Ultra Fine™ erbium laser used for skin resurfacing. 
(Photo courtesy: Coherent Medical Group, Santa Clara, CA.) 



Dermabrasion — a "sanding" of the skin using an abra- 
sive rotary instrument to remove scars, acne, or dam- 
age done by exposure to the sun. 

Laser Surgery — using a highly concentrated, focused 
beam of light to eradicate unsightly skin abnormalities 
such as tattoos, port-wine stains, birthmarks, and bro- 
ken blood vessels. The C0 2 laser is the most common 
type used in dermatology practice. The unit shown in 
Figure 4-115 requires a standard 1 1 0/1 1 5-volt electri- 
cal outlet and is air cooled. Another commonly used 
laser is the erbium:YAG (Figure 4-116). The diode 



laser in Figure 4-117 is used for hair removal. (The 
reader is referred to a discussion of lasers under the 
Ophthalmology section of this chapter and also to 
Chapter 7.) 

Mohs' Histographic Surgery — a specialized surgical 
technique developed by Frederic Mohs, M.D., some 50 
years ago, it is a method of detecting the root of the 
tumor through the use of a sequential examination of 
tissue with a microscope immediately after the tissue 
has been excised. Because the microscope guides the 
physician in how much skin needs to be removed, tak- 



Dermatology 205 





Figure 4-117. LightSheer™ EP diode laser system. Used for perma- 
nent hair reduction. (Photo courtesy: Coherent Medical Group, Santa 
Clara, CA.) 



Figure 4-118. Cryostat used for sectioning tissue. Leica CM 1900. 
(Photo courtesy: Leica Microsystems Inc., Bannockburn, IL.) 



ing "extra margins" of tissue just for safety's sake is 
unnecessary. This technique is used especially where 
cancers have occurred or where they are at high risk 
of recurring. 

This differs from other surgical techniques because the 
excision of tissue is guided by the use of diagrams, dyes, 
microscopes, and special surgical techniques. A local 
anesthetic is used during this procedure. The suite plan in 
Figure 4-108 shows a Mohs' suite with adjacent scrub 



and prep area, pathology lab, and sub-waiting area. Note 
that surgical patients have a direct route to the surgery 
suite, without walking through the examination area. 

Pathology Lab 

The layout of the pathology lab is important. The three main 
pieces of equipment are the cryostat (Figure 4-1 1 8), which 
freezes the tissue specimen and slices thin sections to be 
examined under the microscope (the second piece of 
equipment), and the autostainer, which uses colored dyes 



206 Medicine: Specialized Suites 



to stain the tissue. The cryostat should be opposite the 
autostainerto save steps, and the autostainer must be next 
to the sink as it connects, through a hole in the countertop, 
to water and drain (see layout in Figure 4-108). A stainless 
steel counter and sink are best as the dyes stain badly. The 
autostainer needs an electrical outlet and fume hood; some 
require a water source. Autostainers come in various sizes, 
which allows for considerable flexibility in tight spaces. 
Some are 60 inches long but only 6 to 10 inches deep, 
which means they can be placed on a 6- to 10-inch-deep 
shelf over the countertop (allow clearance for the hinged lid 
to open) to save space (Figure 4-119). Excellent lighting is 
essential. Other room requirements are an undercounter 
refrigerator for meds, considerable storage for gallon bot- 
tles of fixative and reagents for the autostainer, and a low 
countertop (less than 30 inches high) with knee space to 
support a heavy microscope without incurring vibration. 
The microscope should be close to the cryostat. The 
sequence is that the tissue goes first to the cryostat, then to 
the stainer, and, finally, to the microscope. 

Storage and Surgery 

Both the general surgery room and the Mohs' room 
require a full wall of cabinets to store many supplies and 
disposables. 

Patient Flow 

A diagram or map is made during Mohs' surgery to guide 
the excision and examination of tissue. While each 
sequential specimen is stained, frozen, and examined 
under the microscope, patients may leave the office and 
return 45 to 60 minutes later. 



Psoralen Ultraviolet Light 

Psoralen ultraviolet light, type A (PUVA), is used for treat- 
ment of severe psoriasis that cannot be controlled by con- 
ventional therapies, including ultraviolet light, type B. 
Psoriasis is a noncontagious skin disease characterized 
by elevated red patches on the skin, covered by a dry 
scale. The disease is the result of an excessive buildup of 




Figure 4-119. Tissue staining device used in Mohs surgery pathology lab. Linistain™ GLX Random Access 
Stainer. (Photo courtesy: Thermo Shandon, Pittsburgh, PA.) 



skin cells. PUVA reduces this cell reproduction and tem- 
porarily clears symptoms for anywhere from a few weeks 
to a couple of years. 

PUVA involves a combination of long-wave ultraviolet 
light (type A) and a prescription oral medication. Patients 
usually require three treatments a week for a total of 
approximately 30 treatments. 

Most dermatologists do not do PUVA treatment in their 
offices because PUVA equipment is fairly expensive, 
requires a dedicated area, and would need a high volume 
of patients to make the investment worthwhile. The equip- 
ment generates a great deal of heat, and a separate air- 
conditioning unit is required for the PUVA treatment room. 



Other Design Considerations 

Dermatologists dispense a lot of drug samples, salves, 
ointments, and shampoos. A specialized closet should be 
provided in a convenient location in the corridor for stor- 
age of drug samples. The closet might have doors fitted 
with compartments or bins for sorting and making acces- 
sible frequently used products (Figure 4-120). 



Interior Design 

There are no special interior design considerations in a 
dermatology suite. However, lighting is critically important 



Dermatology 207 





Figure 4-120. Drug sample cabinet. {Design: Jain Malkin Inc.) 



Figure 4-121. Sub-waiting area, dermatology suite. Note effect of planters used to divide 
room and to create privacy. (Architecture/interiors: Richard Deno, Cardiff, CA; Furniture: 
Kathy Burnham; Art: Richard Fitzpatrick, M.D.; Photographer: Kim Brun.) 



in all areas. Full-spectrum lamps are best for evaluating 
skin tones. Refer to Chapter 13. Patients are all ages and 
in relatively good health. Exam rooms are often used for 
treatment; therefore, a hard-surface floor is preferable to 
carpet. The use of planters to provide privacy for sub- 
waiting areas (Figure 4-121) is an interesting space-plan- 
ning device. 



ORTHOPEDIC SURGERY 

An orthopedic surgeon deals with diseases, fractures, or 
malformations of the bones, as well as arthritis, birth 
defects, industrial accidents, and sports injuries that 
affect the bones and joints. Some orthopedic surgeons 
specialize in hand surgery. With a tendency to group in 
large practices, it is not uncommon to find six or seven 
physicians working in the same office (Figure 4-122). 



208 Medicine: Specialized Suites 



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7260 SF 
Figure 4-122. Space plan for orthopedic surgery, 7260 square feet. {Design: Jain Malkin Inc.) 



\3 D , 



P\ 



LIBRARY & 

PATIENT 
EDUCATION 



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THERAPY 



FILM 
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Orthopedic Surgery 209 



Table 4-7. 

Analysis of Program. 

Orthopedic Surgery 



No. of Physicians: 



Consultation Rooms 2@ 


12 


X 12 


= 288 


Exam Rooms 2@ 


9 


X 12 


= 432 a 


Cast Rooms 


12 


X 12 


= 144 


Business Office 


14 


X 16 


= 224 


Office Manager 


10 


X 10 


= 100 


Toilets 2@ 


7 


x 8 


= 112 


Staff Lounge 


10 


x 10 


= 100 


Waiting Room 


16 


X 20 


= 320 


Physical Therapy (Optional 




— 




Tech Workstation 


6 


x 8 


= 48 


Radiology 


12 


x 14 


= 168 


Darkroom 


6 


x 8 


= 48 


Storage and Film Filing 


10 


X 12 


= 120 


Film Viewing 


8 


x 8 


= 64 


Subtotal 






2168ft 2 


20% Circulation 






434 


Total 






2602 ft 2 



12 X 12 


= 576 


6@ 


12 


x 12 


= 864 


10 X 10 


= 800 


8@ 


10 


x 10 


= 800" 


12 X 12 


= 288 


2@ 


12 


X 12 


= 288 


20 X 20 


= 400 




20 


X 26 


= 520 


10 X 10 


= 100 




10 


x 10 


= 100 


7X8 


= 112 


3@ 


7 


x 8 


= 168 


10 X 12 


= 120 




14 


x 16 


= 224 


24 X 30 


= 720 




24 


x 30 


= 720 


— 






20 


x 25 


= 500 


6X8 


= 48 


2@ 


6 


x 8 


= 96 


12 X 14 


= 168 




12 


x 14 


= 168 


6x8 


= 48 




6 


x 8 


= 48 


10 x 16 


= 160 




12 


x 16 


= 192 


8x8 


= 64 
3604 ft 2 

721 
4325 ft 2 




8 


x 8 


= 64 
4752 ft 2 

950 
5702 ft 2 



"Assumes one physician is seeing patients while the other is in surgery. 

b \n a six-person practice, it is unlikely that more than three or four surgeons would be in the office at the same time. 



Schedules may be arranged so that each doctor performs 
surgery two days a week, is off one day, and is in the 
office the balance. Therefore, all the surgeons are seldom 
in the office at once. 



Required Rooms 

A two-physician practice would typically have four exam 
rooms, one cast room, a small nurse or tech station, two 
consultation rooms, a large business office, a large wait- 
ing room, a radiology room with darkroom and tech work- 
station, a toilet room, and a large storage and film filing 
room (Figure 4-124). A larger practice might also have a 



physical therapy room, additional cast rooms and exam 
rooms, and a sit- down film viewing area adjacent to the 
radiology room (Figure 4-122). Orthopedists typically do 
not have conventional nurse stations; it is more a work- 
station for the techs who assist the physician in the exam 
rooms. 

Physical therapy (PT) is an ancillary service affected 
by the Stark legislation, designed to eliminate conflict-of- 
interest self-referral opportunities for physicians. This 
has reduced the number of PT facilities associated with 
physicians' offices, as has managed-care contracting, 
which may dictate that patients go to specific facilities for 
physical therapy services. If an orthopedist has a facility 
adjacent to the suite, it must have its own entrance 
(Figure 4-122). 



OQTttOPZD\C SUR6EtQY 




Figure 4-123. Schematic diagram of an orthopedic surgery suite. 



210 Medicine: Specialized Suites 



89-0" 












KIDS' 
PLAY 
PIT 











ORTHOPEDIC SURGERY 



3204 SF 



Figure 4-124. Space plan for orthopedic surgery, 3204 square feet. {Design: 
Jain Malkin Inc.) 



Examination Rooms 

Exam rooms may be 9X12 or 10X10 feet since an 
orthopedist uses a 24- to 27-inch-widex78-inch-long 
table (sometimes custom built), which may be placed 
against the wall to save space (Figure 4-125). Some 
orthopedists prefer to place the head of the table per- 



pendicular to the wall so that they can walk around three 
sides of it (Figure 4-126), in which case the room needs 
to be 1 feet wide. 

The table will frequently have pull-out leaves for exami- 
nation of limbs, and the lower portion of the table may be 
enclosed for bulk storage. Sometimes a row of drawers is 
provided alongside the bulk storage portion of the cabinet. 



Orthopedic Surgery 21 1 




Digital Technology 

A workstation with computer central to the exam rooms, 
at stand-up height, makes it easy for techs and physi- 
cians to retrieve lab results and, with the proper type of 
monitor, view digital X-rays (Figure 4-127). View box illu- 
minators (preferably recessed into the wall) should also 
be provided for viewing film-based X-rays. There is con- 
siderable interaction between physicians and techs in the 
examination area and this centralized hub facilitates com- 
munication. The suite in Figure 4-127 is set up for digital 
X-ray but accommodates film filing storage for historical 
films prior to conversion to a digital system. 




Figure 4-125. Examination room, orthopedic surgery. (Design: Jain Malkin Inc.; 
Photographer: John Christian.) 



••flRl— J* 



Figure 4-126. Examination room, orthopedic surgery. {Design: Jain Malkin Inc.; Photographer: Michael 
Denny.) 



212 Medicine: Specialized Suites 



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CONSULT 



ORTHOPEDIC SURGERY 



4744 SF 
Figure 4-127. Space plan for orthopedic surgery, 4744 square feet. (Design: Jain Malkin Inc.) 



Orthopedic Surgery 213 




Figure 4-1 28a: Hand room, orthopedic surgery. (Design: Jain Malkin Inc.; Photographer: John Christian.) 



Figure 4-1 28b: Hand 
room, detail of cabinet. 
(Design: Jain Malkin Inc.) 




Hand Surgeon 

A hand surgeon works at a T-shaped desk (Figures 
4-1 28a and 4-1 28b). The patient is seated on one side of 
the stem of the "T" and the surgeon on the other. Drawers 
and a flip-top countertop hold instruments and tools. This 
room may be as small as 8X8 feet. 

A hand surgeon also requires a treatment room or 
cast room (Figure 4-129) for dressing wounds and build- 
ing casts. Removal of sutures can be done in the hand 
room. Each exam room and cast room must have a dou- 
ble-panel X-ray film illuminator (Figure 4-130) recessed 
into the wall or surface mounted, at a stand-up height 
(see the Appendix). As digital X-rays become more stan- 
dard, flat-panel monitors and keyboards will need to be 
accommodated. 



Cast Room 

The cast room will have one full wall of cabinets designed 
precisely to accommodate the numerous splints, bandag- 
es, plaster, and required tools (Figure 4-1 31). The design 
of a cast cabinet is extremely important to the efficiency 
of the room. Plaster comes in rolls in widths of 2, 3, 4, and 
6 inches. Slots in the face of the cabinet allow the rolls to 
feed through easily, when pulled. Stockinette may be fed 
through other slots. Drawers hold padding; open bins hold 
elastic bandages; and a drawer contains cast tools. Each 
orthopedist seems to have a preferred arrangement of 
drawers, slots, and bins on the cast room cabinet, but all 
cast cabinets are composed, in one arrangement or 
another, of the above components. Sometimes a prefab- 
ricated cast cart is used for this purpose. 

A large hinged trash bin should be built into the cabi- 
net, if space permits. If possible, this bin ought to be vent- 
ed to the outside, since cast cutoffs have a foul odor. If 
this is not possible, the room should have an exhaust fan. 
The sink in the cast cabinet should have wrist blade 
faucets, or foot-pedal control, a gooseneck spout (so a 
bucket can be put under it), and a plaster trap. 



214 Medicine: Specialized Suites 




Figure 4-129. Cast room. {Design: Jain Malkin Inc.) 



Figure 4-130. Double-panel view box. {Photo courtesy: GE 
Medical Systems, Waukesha, Wl.) 



One must bear in mind that surfaces of the cast room 
must be washable since the room is exposed to plaster 
dust when casts are sawed off and wet drippings when 
new casts are built. A sheet vinyl floor and vinyl wallcov- 
ering are recommended. 

Orthopedists often use Fiberglas casts. This requires 
no special accommodation in the cast room as the 
Fiberglas comes in rolls, like the plaster. The rolls come 
sealed in foil packets in varying widths. The same type of 
padding is used for both plaster or Fiberglas casts. 
Private cast rooms (Figure 4-122) are preferable to multi- 
station cast rooms (Figure 4-127) as they can also be 
used as exam rooms. 



Minor Surgery 

Some orthopedists use a minor surgery room for proce- 
dures such as removing foreign bodies or removing toe- 
nails, for example. 



Consultation Room 

The consultation room will usually be used as the doctor's 
private office and as a place to return phone calls and 
review X-ray films. For this purpose, a four-panel illumi- 
nated film viewer should be located to the side of or 



Orthopedic Surgery 215 



-6"± 




BASE CABINET IS 24" DEEP 
UPPER CABINET IS 14" DEEP 



DOOR AND DRAWER SCHEDULE 


®(D©@®© 


DRAWERS WITH SIDE ROLLERS, A, B & C MUST HAVE CLEAR DEPTH OF 4" INSIDE. 


©©©© 


-NO SIDE ROLLERS. BOTTOM DRAWER GLIDE ONLY. THESE DRAWERS ARE RARELY OPENED. 


®0© 


OPEN SHELVES FOR SPINTS (CUBBY HOLES). 


® 


DRAWER FOR 4" BIAS. DRAWER GLIDE ON BOTTOM. 


© 


STOCKINETTE DRAWER. SLOT OPENINGS MUST BE SANDED VERY SMOOTHLY. (NO SNAGS). 


@®@® 


DRAWERS FOR PADDING. 


© 


TILT-OUT TRASH BIN. (HOLDS LARGE PLASTIC TRASH CAN). 



CAST CABINET 



Figure 4-131. Cast cabinet. (Design: Jain Malkin Inc.) 



behind the physician at a sit-down height, usually mount- 
ed over the credenza (Figure 4-132). 

Adjacency of Rooms 

Cast room(s), radiology, and the film viewing area should 
be located in proximity to each other (Figures 4-122, 
4-124, and 4-1 33). There should be a tech work area near 
the cast room and radiology room (Figure 4-134 and see 
Figure 5-18). It would have a 6-foot-long countertop and 
X-ray view boxes and be close to the darkroom and film 
processor. Sometimes the X-ray tech assists the physi- 
cian in the cast room. 



Radiology Area 

The reader is directed to Chapter 3, Family Practice, for 
design of an X-ray room, control area, and darkroom. 
Open shelves (or deep chart file cabinets) must be pro- 
vided for film filing. Shelves should have vertical dividers 
every 18 inches, since films are heavy and unwieldy and 
tend to slump over if not packed tightly between divider 
supports. X-ray jackets (the paper storage envelopes) are 
14!4x17 1 / 2 inches, and shelves should be shallow enough 
so that about 2 inches of the film jacket hang over the 
edge of the shelf for ease of access. 

One must be sure that the door to the X-ray room is 
large enough to move in the equipment. The ceiling 
height of this room must be at least 9 feet high. 

Digital X-Ray 

Predictions are that digital X-ray will not become wide- 
spread in orthopedic offices for a number of years due to 
the expense of conversion. When new equipment is pur- 
chased, it will likely be digital but orthopedists who have 
been in practice awhile will still require storage of films and 
conventional film illuminators in addition to a digital work- 
station for reviewing X-rays (Figure 4-127). And there 
would be a need to print digital images on opaque or trans- 
parent paper. Along with this, monitors to receive digital X- 
rays may be located in the consultation room, cast room, 



216 Medicine: Specialized Suites 



and tech workstation. Swissray International (Elmsford, 
New York) offers a software package called OrthoVision to 
enable an orthopedic practice to convert to digital imaging. 

Other Considerations 

Corridors of the suite should be 5 to 6-foot wide for easy 
passage of patients on crutches and in wheelchairs. The 
corridor is also used as a gait lane. Sometimes a patient 
education room is included (Figure 4-135). Surgeons find 
it time saving to purchase videotapes explaining certain 
frequently performed procedures to patients (joint 
replacement, arthroscopy, etc.). 

Toilet rooms in this suite, as in any other, must accom- 
modate the handicapped (see the Appendix). 



Interior Design 

The interior design of the suite must please patients of all 
ages. Artwork might include sports photos or perhaps edu- 
cational exhibits dealing with prevention of sports injuries 
or other orthopedic topics. All floors except cast rooms and 
the X-ray room can be carpeted with a level-loop commer- 
cial carpet glued to the slab without a pad. Any other type 
of installation will be unsuitable for wheelchairs and people 
on crutches. A firm feeling under foot is desirable here. 

The waiting room needs to be large enough to accom- 
modate people in wheelchairs without ambulatory 
patients tripping over them. Chairs should be firm, with 
high seats, and have arms to help arthritic patients, for 
example, raise themselves out of the chair. Chairs should 
be well balanced, to avoid tipping when patients lean on 
them for support. It is practical, in an orthopedic waiting 
room, to offer several types of seating to provide comfort 
for the widest number of people. In Color Plate 1 9, Figure 
4-136, a large saltwater aquarium is the focus of the 
room. It is serviced from a closet behind it. 

If the budget allows, walls (at least corridor walls) 
should be covered with commercial vinyl wallcovering, 
since wheelchairs and crutches can damage paint. 




"Mfi 







Figure 4-132. Consultation room, orthopedic surgery. (Design: Jain Malkin Inc.; Photographer: Michael Denny.) 



Orthopedic Surgery 217 




STAFF 
ENTRY 



ENTRY 



ORTHOPEDICS 



1856 SF 



Figure 4-133. Space plan for orthopedic surgery, 1856 square feet. (Design: Jain Malkin Inc.) 



218 Medicine: Specialized Suites 



Figure 4-134. Tech work area. Control (generator) for X-ray unit is out- 
side room. Lead glass window provides view into X-ray room. 
Emergency electrical shutoff panel located here. Automatic processor 
and tech viewing area can be seen in rear. Note: This photo shows an 
older-model film processor, but it is illustrative of a film-based tech 
work area. A brochure rack makes it easy for tech to distribute relevant 
literature to patients. (Design: Jain Malkin Inc.; Photographer: John 
Christian.) 




Figure 4-135. Patient education room, orthopedic surgery. {Design: Jain Malkin Inc.; Photographer: John Christian.) 



Orthopedic Surgery 219 



60-0" 




ALLERGY 



3720 SF 
Figure 4-137. Space plan for allergy, 3720 square feet. (Design: Jain Malkin Inc.) 



ALLERGY 

Patient Histories 

Allergy is defined as an overreaction in some individuals 
by a specific defense mechanism of the body responding 
inappropriately to certain environmental substances and 
resulting in annoying and sometimes debilitating reac- 
tions. The substances to which these reactions occur are 
called allergens. A methodically detailed patient history 
is a part of any preliminary examination or interview. 
Often, a lengthy printed questionnaire is given to the 
patient prior to the first visit to be filled out at home. In 
some situations, patients may fill out a history, or update 
it, while sitting in the waiting room with clipboard in hand. 
Several alcoves with countertop writing surface, chair, 
and light may be included in or near the waiting room 
(Figures 4-137 and 4-138). Computers will increasingly 
be used for patient histories. A patient may be able to log 
on to a physician's Web site, answer the questions on 
line, and email the completed questionnaire to the physi- 
cian's office where it can be downloaded into the 
patient's electronic medical record, if such exists. 
Software to handle this type of confidential information in 
the medical setting is already available to safeguard 
patients' privacy during transmission, as explained in 
Chapter 3. (See Figure 4-139.) 

Providing carrels or alcoves in the waiting room allows 
patients to update information on their electronic medical 
record to reflect changes since their last visit. They can 
also be used for accessing information about allergies on 
the Internet; the physician may have set up on the home 
page icons for Web sites with the best medical resources. 
These carrels, if equipped with TV monitor and VCR, can 
also be used to view videotapes. 

Frequently, a combination of staff interview and printed 
questionnaire will be used. In this situation, an alcove 
may be created off of the corridor for a number of tablet 
arm chairs; however, privacy must be considered and the 
area should be located where patients in the waiting room 
cannot overhear the conversation. The suite plans in 



220 Medicine: Specialized Suites 




PEDIATRIC ALLERGY 



4136 SF 

Figure 4-138. Space plan for pediatric allergy, including research area for clinical studies, 4136 
square feet. (Design: Jain Malkin Inc.) 



Allergy 221 











Table 4-8. 




















Analysis of Program. 
Allergy 












No. of Physicians: 




1 








2 








3 




Exam Rooms 2@ 


8 


X 12 = 


192 


4@ 


8 


X 12 = 


384 


7@ 


8 


X 12 = 


672 


Treatment Rooms 


12 


X 12 = 


144 


2@ 


12 


X 12 = 


288 


2@ 


12 


X 12 = 


288 


Consultation Rooms 


11 


X 12 = 


132 


2@ 


11 


X 12 = 


264 


3@ 


11 


X 12 = 


396 


Waiting Room 


16 


X 16 = 


256 




16 


X 26 = 


416 




20 


X 25 = 


500 


Sub-Wait (shots) 


10 


X 10 = 


100 




10 


X 15 = 


150 




12 


X 20 = 


240 


Storage 


6 


X 8 = 


48 




6 


X 8 = 


48 




8 


X 8 = 


64 


Nurse Station/Lab 


12 


x 16 = 


192 




12 


X 14 = 


168 




10 


X 32 = 


320 


Toilets 2@ 


7 


x 8 = 


112 


3@ 


7 


X 8 = 


168 


3@ 


7 


X 8 = 


168 


Shots 


(Combined w/lab) 




8 


X 10 = 


80 




8 


X 10 = 


80 


Recovery/Reaction 


6 


x 8 = 


48 




8 


x 10 = 


80 




8 


x 10 = 


80 


History Alcoves 




a 






8 


x 10 = 


80 




8 


x 10 = 


80 


Test Rooms* 


(2 persons) 


96 




(3 persons^ 


144 




(4 persons) 


192 


Audiology 




— 






8 


x 10 = 


80 




8 


x 10 = 


80 


ENT Exam (optional) 


8 


X 12 


96 






— 








— 




Staff Lounge 


10 


x 10 = 


100 




10 


X 12 = 


120 




12 


X 14 = 


168 


Business Office c 


12 


X 20 = 


240 




12 


X 24 = 


288 




14 


X 22 = 


308 


Subtotal 






1756 ft 2 








2758 ft 2 








3636 ft 2 


20% Circulation 






351 








552 








727 


Total 






2107ft 2 








3310 ft 2 








4363 ft 2 



ALU&R&Y 



"History-taking alcoves may be worked into the circulation area or waiting room or be located in a dedicated room. 
''May be one room with cubicle drape separation or individual rooms with pocket doors, 
includes reception, appointments, bookkeeping, and insurance. 

Note: The above spaces may vary greatly, depending on the location of shot, test, and recovery/reaction rooms and how they 
are combined. 








■-&T&. 



IapnsultHtreat. I treat. 

Figure 4-139. Schematic diagram of an allergy suite. 



Figures 4-137, 4-138, and 4-140 indicate various options 
for handling patient histories. If the practice includes a 
large number of pediatric cases, the interview room will 
have to accommodate one or both parents, the child, and 
the interviewer, since the parents will usually answer 
questions for the younger child. 

Some allergists prefer that the patient history be taken 
by the staff. In this case, small rooms (6X8 feet) may be 
provided with a desk (2x4 feet is adequate) and a chair 
for both the patient and the interviewer, and perhaps one 
for a companion (Figure 4-137). The nurse can also take 
the history in a standard exam room. Sometimes aller- 
gists may take the patient history themselves, using the 
consultation or exam room. 



222 Medicine: Specialized Suites 



84-6" 




ALLERGY 



2366 SF 
Figure 4-140. Space plan for allergy, 2366 square feet. [Design: Jain Malkin Inc.) 



Pediatric Allergy 

There are pediatric allergists whose entire practice 
focuses on children (Figure 4-138). These offices should 
be designed according to the needs of an allergist, but 
with design and color palette suitable for a pediatrician's 
office (Figures 4-141 and 4-142). The treatment or test 
rooms, instead of having number designations, may 
have large animals or cartoons painted alongside them 
so that staff can tell the child to go to the "butterfly" or 
the "frog" room. However, one must take care to not 



make it too pediatric, which may offend adolescent 
patients. A digital technology theme, with interactive art, 
would appeal to children of all ages. It should be noted 
that, in a pediatric practice, there will be a high volume 
of shots after school. 



Patient Flow 

Allergy patients generally fall into several categories in 
terms of flow and treatment. 



Allergy 223 




Figure 4-1 41 . Waiting room for pediatric allergist. {Design: Jain Malkin Inc.; Photographer: John Waggaman.) 



Acutely III 

These patients proceed to a treatment room immediately 
upon entering where they are evaluated by a nurse and 
the physician who will make a decision about the imme- 
diate intervention required. This may include treatment 
with an aerosolized nebulizer, the placing of an IV line in 
the patient's arm, delivery of oxygen, or administration of 
systemic medications. The procedure room would be 
used for the more acutely ill patients, most often those 
with more severe acute exacerbations of asthma. 



nesses, will visit an allergist to evaluate these problems 
and develop a treatment plan. These patients will review 
their medical histories with the nurse and physician, have 
a physical examination, and often undergo various tests, 
which may include skin tests, pulmonary function tests, 
screening audiology, tympanometry, and, in some prac- 
tices, rhinolaryngoscopy and inhalation challenge tests. 
After the physician's examination of a new asthma 
patient, spirometry (measuring lung capacity) is part of 
the routine work-up. It can be done in the lab or the pro- 
cedure room. Afterward, a nebulizer treatment with a 
bronchodilator medication may be administered for diag- 
nostic or therapeutic reasons. Established asthmatic 
patients periodically undergo spirometry as part of their 
ongoing care. Providing a room for this purpose near the 
lab (Figure 4-138) is useful. Allergists perform tympa- 
nometry and audiology screening to diagnose middle-ear 
disease. Rhinolaryngoscopy is performed in an exam 
room with a specialized equipment cart (refer to the dis- 
cussion in the Otolaryngology section) to evaluate the 
condition of the sinuses, the nasal cavity, larynx, and 
throat. If a fiber-optic scope is used with a tiny camera on 
the end (connected to a video monitor), the internal struc- 
tures can be visualized in color on the monitor, which can 
be helpful to both the physician and the patient. 

Desensitization Injections 
(Allergy Shots, Immunotherapy) 

A series of injections may be given once or twice per 
week for a period of months, eventually reaching a four- 
week interval that may continue for several years. 
Patients check in at the reception desk and proceed 
immediately to the nurse station for the shot. Afterward, 
the patient will sit in a sub-waiting area, in view of the 
nurse, for a period of 20 to 30 minutes to check for an 
adverse reaction. It is necessary to find out how many 
patients come in for shots at one time to make sure that 
the sub-waiting area will accommodate them. 



Initial Evaluation 

Individuals experiencing a variety of respiratory tract, 
skin, and miscellaneous other reactions, or chronic ill- 



Follow-Up Visits 

From time to time, patients will return to report new symp- 
toms or to have a tuneup. These are routine visits such as 



224 Medicine: Specialized Suites 



might be encountered in any primary-care or specialist's 
medical office. The patient would be seen by the physi- 
cian, nurse practitioner, or medical assistant in the exam 
room, followed by any procedures deemed necessary by 
the doctor or nurse practitioner. 

Inhalation Challenge Tests 

In some practices, patients suspected of having asthma, 
or those participating in research studies, undergo the 
serial inhalation of chemicals or allergens known to 
induce asthma in the procedure room. A dosimeter and 
spirometer are used to provide exact dosages and to 
measure effects, respectively. 

Clinical Research 

Some allergists are involved in clinical research studies. 
Patients participating in these investigations may be pres- 
ent 10 to 12 hours, or more, in the physician's office 
where they are given medications and have their lung 
functions tested periodically. It's important to have a 
lounge setting for this purpose and a pediatric playroom 
(for pediatric research), as well as a kitchen to prepare 
food for patients and their companions (Figure 4-138). 
This involves a considerable outlay of space, which, when 
patients are not present, may double as a staff lounge. 
However, it is unlikely the research office could be shared 
by other personnel due to the amount of records, paper- 
work, and experimental drugs stored there during ongo- 
ing clinical trials. 

The clinical research nurse does a lot of teaching in 
this room. There is a great deal of paperwork and mail, 
both received and sent out, which requires a work count- 
er with postage meter, letter opening machines, copier 
and fax machine, printers and computers. In the evening, 
the waiting room or research lounge area can be used to 
explain the study to groups of 20 people or more to inter- 
est them in participating. Lots of file cabinets and book- 
shelves are required for binders, journals, paperwork, 
and study drugs. 

Each research nurse needs desk and file space as well 
as shelves for manuals and binders. Files cannot be 
stored where patients can access them. An 18-inch-deep 




'ill'v Mm- 

Figure 4-142. Secondary waiting room, pediatric allergy. {Design: Jain Malkin Inc.; Photographer: John Waggaman.) 



storage area (cabinets with locking doors) is needed for 
drug samples involved in the studies. Opposite this cabi- 
net, a shelf or work counter should be available to place 
a box while it is being accessed. It is clear, from looking 
at Figure 4-138, that a sizable area is required for clinical 
studies. Since this is a lucrative endeavor, however, 
resulting in sizable fees from pharmaceutical companies, 
the cost of the lease space is usually not an issue. 



Patient Volume 

An allergy practice has a high volume of patients (as high 
as 50 to 60 per doctor per day), which falls into two cate- 



Allergy 225 



gories: short visit (to receive an injection or have a follow- 
up visit) and long visit (patient interview, procedures). Of 
the 50 patients per day per physician, 20 to 25 will be 
shots, which means they likely will not see the physician. 
Due to the high volume of patients, an efficient layout is of 
utmost importance. A large number of patients come once 
or twice a week, and others at various intervals up to four 
to six weeks, to receive allergy shots. Thus, the nurse sta- 
tion where injections are given should be located off the 
waiting room or just inside the suite near the waiting room 
so that these patients do not have to mingle with the long- 
visit patients (Figures 4-137 and 4-140). Functions requir- 
ing quiet, such as audiology screening, as well as the 
research area (if it exists), should be at the rear of the suite. 
Look at the nurses' principal functions and activities and 
group them together to avoid needless steps. 



Injection Protocol 

After receiving the injection, as just explained, the patient 
will return either to the main waiting room or to a sub- 
waiting area off of the nurse station to sit for a period of 
time (typically 20 to 30 minutes) to check for an adverse 
reaction. The waiting room must be large enough to 
accommodate the high volume of patients. One may wish 
to include a small "reaction" room furnished with a cot and 
chair so that a patient after receiving an injection may lie 
down and be observed by the nurse (Figure 4-140). 



ties. Skin tests may be performed in small procedure 
rooms, 8x8 feet or 8x10 feet in size, or in a large room 
that has been divided into 6x8 foot or 8x8 foot areas by 
way of a ceiling-mounted cubicle drape or, if more priva- 
cy is desired, low partitions, closed off with a drape on the 
open end. The patient lies on a physical therapy-type flat 
table that is often placed against a wall. The technician 
sits alongside the patient, working off of a cabinet or a 
mobile cart. A rack of small vials containing allergens is 
carried from room to room and placed on the cart. This 
can also be done in standard exam rooms. 



Treatment or Procedure Room 

Patients who are in no immediate physical danger are 
seen in test rooms or exam rooms, but patients who are 
experiencing severe symptoms such as asthma or vomit- 
ing may be examined in a treatment room where the staff 
has access to IV equipment and respiratory equipment 
such as nebulizers, oxygen (usually portable), and med- 
ications that may need to be injected. 

After a diagnosis has determined to which agents the 
patient is sensitive, desensitization treatment begins. The 
injections and tests are done by nurses and aides; there- 
fore, one doctor may have several aides. 



Audiometry 



Skin Tests 

After the physician has reviewed or completed the initial 
history taking and the physical examination, the patient 
frequently has skin tests administered by a nurse or tech- 
nician. Two types of skin tests are used, either alone or in 
combination. If both are used, the doctor usually starts 
with prick tests on the back or upper extremities on a 
patient who is sitting or lying down. This may be followed 
by intradermal tests, in which a small amount of an aller- 
gen is injected just under the skin, on the upper extremi- 



A small number of otolaryngologists also do allergy. Full 
audiometry testing as well as testing for hearing aids may 
be provided. (Refer to the Otolaryngology section for pho- 
tos of an audio testing booth.) Trained allergists may per- 
form simple audiometry screening and/or tympanometry. 
Although this type of test equipment is, for the most part, 
digital, pediatricians or allergists who wish to do basic 
screening may use a low-cost manual audiometer (Figure 
4-143) that sits on a table, with the patient (wearing head- 
phones) on one side and the staff person on the other. 
The room should be as soundproofed as possible to 
screen any extraneous noise and to enable the patient to 



226 Medicine: Specialized Suites 



totally concentrate on the sounds being generated by the 
machine. A tympanometer (Figure 4-144) is sometimes 
combined with the audiometer in one piece of equipment. 
The tympanometer diagnoses middle-ear disease, which 
may indicate eustachian tube dysfunction. 



Other Considerations 

The physician needs a fairly large consultation room with 
a desk since not only will the results of the testing and the 
prescribed treatment often be discussed there, but the 
doctor's reference materials, books, and files will be 
stored there. The nurse station/lab in this suite must be 
large and have space for two or more full-size refrigera- 
tors for storage of injectables and allergen extracts for 
testing and desensitization. 



Interior Design/Construction Issues 

Heavy textures, irregular surfaces (e.g., some acoustic 
ceiling tiles), "shag" carpeting, and many fibers (wool, in 
particular) collect dust and can cause problems for those 
with allergies and are to be avoided in the office. Similarly, 
draperies, because they collect dust, are to be avoided in 
favor of PVC vertical blinds. All materials in this suite must 
be easy to dust or sanitize, and they must be as hypoal- 
lergenic as possible. Avoid dust shelves — any nonfunc- 
tional surface that might collect dust. Upper cabinets, for 
example, should continue to the ceiling. An electronic fil- 
ter on the HVAC system can be useful. 

There are certain building materials that are known to 
off-gas VOCs, the most formidable of which is formalde- 
hyde for many individuals. Particle board, often used as 
the substrate for plastic laminate in cabinets and case- 
work, is made with formaldehyde. At considerable addi- 
tional expense, one may buy domestic particle board — 
made without formaldehyde — but if it is stored even for a 
period of days in a millwork shop alongside conventional 
particle board, it will quickly pick up the odor like a 
sponge. An alternative to plastic laminate casework is 





Figure 4-143. Manual audiometer for screening 
hearing. (Photo courtesy: Welch Allyrf, Skaneates 
Falls, NY.) 



Figure 4-1 44. Tympanometer for diagnosing middle- 
ear disease. (Photo courtesy: Welch Allyrf, 
Skaneates Falls, NY.) 



solid hardwood cabinets with solid surface tops such as 
Corian. Moreover, the contact cements used with plastic 
laminates are high in VOCs. The water-based equivalents 
tend not to be as effective and often will invalidate a war- 
ranty by the fabricator. The EPA (Environmental 
Protection Agency) publishes excellent literature listing 
the VOC content and period of years one can expect 
these potentially hazardous agents to off-gas. There are 
numerous excellent resources and books that have been 
written on the topics of "sick building syndrome" and 
"green design." 

There are individuals who are so highly sensitive to the 
components of most construction materials, as well as 
fibers used in textiles and agents used in housecleaning 
solutions, that life from day to day is almost unbearable for 
them, as they try to figure out how to limit their exposure. 
An allergist may develop a subspecialty in treating 
patients of this type, in which case the office should be 



Allergy 227 



designed as "green" as possible. It may be more practical 
for an allergist to rent an old house (assuming it is free of 
asbestos) whose contents may have off- gased may years 
ago, as opposed to renting space in a new medical office 
building. Even in a new building, there are a couple of 
things that can be controlled. Carpet should be unrolled 
and exposed to fresh air to off-gas for a week prior to 
installation. Vinyl wallcovering should be avoided in favor 
of low-VOC, or no VOC, paint, which is readily available 
from most manufacturers. Forbo Marmoleum® is a 
linoleum sheet goods product containing only natural 
materials. It does not need waxing and may be a good 
choice for rooms that are not appropriate for carpet. 
Finally, if operable windows exist, the suite should be fully 
ventilated for at least one week after all finishes have been 
installed, prior to tenant occupancy. Fans are often placed 
at strategic locations in the suite to direct the flow of air 
(which may contain petrochemicals) to keep it moving 
toward the windows. 



HVAC Issues 

Being able to monitor and control the relative humidity, 
especially in humid locales such as Florida and Hawaii, 
will reduce mildew and mold and retard the growth of 
other fungi, bacteria, and dust mites. Keeping the relative 
humidity below 50 percent (which may require dehumidi- 
fication) minimizes these allergens and their irritating by- 
products, which flourish in moist environments. In addi- 
tion, exceeding the standard number of room air changes 
in the HVAC system can keep the air cleaner, as can 
meticulous attention to changing air filters on a regular 
schedule. 



NEUROLOGY 

Neurologists diagnose diseases of the nervous system 
and brain. Their patients are always referred by other 
physicians. Patients may complain of headaches, epilep- 
tic seizures, damage suffered as a result of a stroke, or 



perhaps a cerebral palsy condition that has resulted in 
facial distortion — a distended jaw or a drooping mouth. 
Neurologists manage progressively degenerative dis- 
eases such as Parkinson's disease, Alzheimer's disease, 
multiple sclerosis and Lou Gehrig's disease (amyotrophic 
lateral sclerosis, ALS), which involves considerable "trial 
and error" manipulation of drugs. Responsibility for diag- 
nosing tumors of the brain and spine falls to the neurolo- 
gist, who also manages the patient's care postsurgical^, 
if indicated. 

This is a low-volume specialty, with the taking of a pre- 
liminary history and an interview in the physician's consul- 
tation room or exam room requiring 20 to 45 minutes for 
new patients. Occasionally, there may be a small exam 
room opening off of the consultation room (Figure 4-145). 
Two exam rooms per physician is generally adequate. 

A patient education room with TV and VCR and CRT 
with Internet access is useful for patients and their fami- 
lies to learn about neurodegenerative diseases. 

Planning for patients in wheelchairs is mandatory in 
this specialty. Individuals with spinal cord injuries may 
have large motorized wheelchairs possibly with attached 
portable ventilators. The waiting room and exam rooms 
must easily accommodate wheelchairs; a corridor width 
of 5 feet is optimal. 



Diagnostic Procedures 

Neurologists used to do numerous diagnostic tests within 
the office, but as reimbursement has steadily decreased, 
in some locales, there is a trend toward sending the 
patient to the hospital for tests. This means the physician 
need not invest in the equipment or bear the cost of addi- 
tional space to accommodate it. Moreover, the increased 
availability of MRI and CT (computer tomography) scans 
— the gold standard in neurological diagnosis — has 
greatly reduced the number of EEGs (electroencephalo- 
grams) performed although they are still used for epilep- 
sy. It is necessary, nevertheless, for space planners to be 
familiar with this test and equipment. Figure 4-145 shows 
a suite designed to accommodate in-house testing. 



228 Medicine: Specialized Suites 



48-0" 




Figure 4-145. Space plan for neurology, 1536 square feet. (Design: Jain Malkin Inc.) 



After the patient interview, a series of tests may be 
performed. The most common test is the electroen- 
cephalogram (charting of brain waves), commonly 
known as EEG (Figure 4-147). This can be performed in 
a room as small as 8X10 feet if the technician does not 
remain in the room with the patient, but sits in an adjoin- 
ing control room. 



There are two schools of thought on this point. Some 
neurologists feel that the patient is comforted by the tech- 
nician's being in the same room, and others feel that it is 
distracting to the patient. However, most prefer to have 
the tech in the room with the patient. In either case, the 
patient usually sits in a comfortable recliner chair, since 
this seems to make the patient less apprehensive and 



Neurology 229 





Table 4-9. 










Analysis of Program. 










Neurology 








No. of Physicians: 


1 






2 




Consultation Rooms 


12 X 14 


= 168 


2@ 


12 X14 


= 336 


Exam/EMG 


10 X 10 


= 100 




10 X10 


= 100 


Exam Rooms 


8X12 


= 96 


3@ 


8 X12 


= 288 


Business Office 


12 X 14 


= 168 




14 X16 


= 224 


Waiting Room 


12 X 14 


= 168 




14 X16 


= 224 


Toilets 


7X8 


= 56 


2@ 


7X8 


= 112 


EEG/Control 


10 X 12 


= 120 




10 X12 


= 120 


Med. Asst./Tech 


8X8 


= 64 




8X8 


= 64 


Storage 


4X6 


= 24 




6X6 


= 36 


Subtotal 




964 ft 2 






1504 ft 2 


20% Circulation 




193 






301 


Total 




1157 ft 2 






1805 ft 2 



rteojftouoiyf 




c \xcouxr\ot\ , 



Figure 4-146. Schematic diagram of a neurology suite. 




more relaxed. It is not essential but it is helpful to have a 
sink in the EEG room for hand washing. 

There are two ways to administer the EEG. One 
method requires the application of conductive paste at 
the temples before the leads are attached. The paste is 
messy and the patient must have access to a sink or a 
bathroom to wipe it out of his or her hair afterwards. A 
thoughtful designer would provide a vanity counter in the 
bathroom with a paper towel dispenser, a soap dispenser, 
and a place to hang a coat or handbag. While one does 
not wish to encourage the patient to shampoo his or her 
hair in the office, it is necessary to remove the paste at 
least partially. 

The second method is generally considered the sim- 
plest for both the tech and the patient. It involves the use 
of an electrode cap that resembles an old-fashioned 
swimming cap. With this method, there is very little paste 
to wipe off the hair. The EEG procedure takes about 40 
minutes to perform. 

Another commonly performed test is evoked potential, 
which tests the different pathways to the brain (auditory, 
visual, and somatosensory) (Figure 4-148). Both EEG and 
evoked potential testing are done by a technician, and 
both units may be located in the same room (Figure 4-45). 
A room 10X12 feet would be adequate. With the EEG unit, 
the tech sits at the computer keyboard during the proce- 
dure. If the neurologist prefers that the technician be in an 
adjoining control room, there must be a large window so 
that the patient can be observed at all times. 

In the test room, locked storage is needed for drugs 
used to sedate patients. Test equipment is all digital. 
Therefore, computer printouts are stored in the patient's 
chart, and compressed digital storage of data is standard. 
Lighting in the test room should be able to be dimmed. 

Frequently, a neurologist will perform EEGs for other 
physicians but have no personal consultation with the 
patient. The EEG technician would perform the test, and 
the printout would be read or interpreted by the neurolo- 
gist, with a report mailed to the patient's physician. 
However, the neurologist would not consult with the 
patient unless the physician, after receiving the report, 
felt the referral was necessary for treatment of the 



230 Medicine: Specialized Suites 





Figure 4-147. EEG machine. {Photo courtesy: Nicolet Biomedical 
Limited, Warwick, United Kingdom.) 



Figure 4-148. Evoked potential machine. (Photo courtesy: Nicolet 
Biomedical Limited, Warwick, United Kingdom.) 



patient's condition. Therefore, a good location for the EEG 
room is near the front of the suite so that these patients 
do not have to pass the consultation room or exam rooms 
in order to reach the test room. 

A neurologist may also perform a spinal tap (to drain off 
fluid) in the office. For this procedure, the neurologist 
would use an exam room with the patient lying on an 
exam table, which is usually placed against a wall. 

Another office procedure is EMG, electromyography, 
which shows if a muscle is deteriorating or can be reha- 



bilitated. It measures the strength of a muscle and indi- 
cates if the nerve has been affected. This test is per- 
formed by the physician, in a dedicated room, with a 
table placed against the wall. The procedure takes about 
half an hour, and the reason for putting it in a dedicated 
room is that it saves time in moving the equipment 
around and in setting up each patient. The room need 
only be 10x10 feet. The equipment is on a mobile cart 
so that the physician can move it around the patient 
(Figure 4-149). 



Neurology 231 




Figure 4-149. EMG machine. (Photo courtesy: Nicolet Biomedical 
Limited, Warwick, United Kingdom.) 



Other examination rooms will have a physical therapy- 
type table, a small sink cabinet, and a wall-mounted diag- 
nostic instrument panel (Figure 3-42) with ophthalmo- 
scope, blood pressure cuff, and otoscope. In addition, 
these rooms may have an eye chart and perhaps an X- 
ray view box. Some neurologists like a scale in each 
exam room. The patient's evaluation of his or her weight 
helps the physician gauge a patient's touch with reality. 

Maximum soundproofing is essential in the test rooms. 
Do not locate the door to a bathroom opposite the door of 
a test room and do not place plumbing for an adjacent 



room on a wall contiguous with walls of test rooms. See 
Chapter 14 for soundproofing construction details. 



Interior Design 

The consultation room should be large and comfortably 
furnished, since patients may be interviewed here. 
Furnishings in this room, and the remainder of the office, 
should be tasteful but understated. All colors and patterns 
should be selected for their restful quality — anything bold 
is to be avoided. One must be particularly aware of pat- 
terns that have a figure-ground reversal or that have a 
visual rhythm. Such patterns may cause seizures in peo- 
ple with certain types of neurological disorders. 

All rooms in this suite may be carpeted. Most carpet 
has sufficient antistatic properties to avoid interference 
from static electricity that might affect electronic testing 
equipment. Lighting should be rheostatically controlled so 
that it can be dimmed when patients are relaxing and 
being tested. 



NEUROSURGERY 

A neurosurgeon's office is often smaller than a neurolo- 
gist's office and does not include diagnostic testing equip- 
ment. All of the tests would be performed in the neurolo- 
gist's office, and the neurosurgeon would mainly see 
patients for preoperative and postoperative consultations. 
Therefore, a small number of examination rooms is neces- 
sary, in addition to a business office, a bookkeeping area, 
and a consultation room for each physician (Figure 4-1 50). 
One exam room per physician is usually adequate since 
the surgery schedule rarely permits all physicians to be 
there at the same time. Each physician may have a private 
secretary to schedule surgeries and handle correspon- 
dence. The interior design of the waiting room should be 
soothing with careful attention to avoidance of geometric 
patterns or elements that may cause a figure-ground rever- 
sal or may "vibrate" or cause dizziness or possibly seizures 
in sensitive individuals (Color Plate 20, Figure 4-151). 



232 Medicine: Specialized Suites 




NEUROSURGERY 



2560 SF 



Figure 4-150. Space plan for neurosurgery, 2560 square feet. (Design: Jain Malkin Inc.) 



PAIN MANAGEMENT CENTERS 

These are hybrid-type suites that are becoming increas- 
ingly common. They involve a multidisciplinary approach 
to the treatment of pain. Frequently, one will find neurolo- 
gists, nutritionists, deep-tissue massage therapists, chiro- 
practors, psychologists, and biofeedback technicians 
working together in a holistic manner to change the 
patient's behavior or symptoms. Some neurologists may 
have one or more biofeedback rooms and physical thera- 
py massage rooms incorporated into their offices. 



In recent years, anesthesiologists have become 
involved in pain management of persons suffering from 
intractable pain. Anesthesiologists who specialize in pain 
management are physicians who have received addition- 
al training in this area after completion of anesthesiology 
training. According to the American Board of Medical 
Specialties, certification in pain management recognizes 
that these physician anesthesiologists have demonstrat- 
ed competence to provide a high level of care either as a 
primary physician or as a consultant to patients experi- 
encing either acute or chronic pain. 



Pain Management Center 233 



Procedures Performed by Anesthesiologists 

Fluoroscopic-guided injections into the epidural space 
can be carried out in a minor procedure room but are more 
commonly done in a hospital or ambulatory surgical cen- 
ter setting as the cost of radiographic equipment would go 
beyond what most physicians would want to invest in their 
offices. All injections, however, are not fluoroscopically 
guided. Sometimes a local anesthetic is injected into soft 
tissue, joints, and the spine. Fluoroscopy is used where 
the space is anatomically small and hitting the target may 
be difficult without the help of fluoroscopy. Often, there is 
a recovery area because patients can get up after the pro- 
cedure and fall. How patients feel after the procedure is 
very important and they might be interviewed in a consul- 
tation room or exam room after recovery. 



Measuring the Problem 

Chronic and intractable pain is a huge problem in that it 
affects approximately 50 million Americans and results in 
considerable loss of productivity and time away from 



work. In the inpatient setting, only recently has pain been 
documented as one of the vital signs. Patients are asked 
to rate their level of pain, which is recorded in their chart, 
along with vital signs. For those with terminal illnesses, 
there's currently much discussion about the appropriate 
use of morphine and other narcotics to end suffering. 

For others, chronic pain — defined as that which no 
longer serves a biologically useful function — is terribly 
debilitating and, according to researchers, can actually 
change the wiring in the brain, spinal cord, and nerve cells 
by triggering the release of proteins that cause tissue dam- 
age. Pain can actually become a disease in itself. Treating it 
is often a trial-and-error process in which sufferers consult 
numerous physicians and therapists trying to find the magi- 
cal cure. Low-back pain is second only to the common cold 
as the most common cause of illness. Other common caus- 
es of pain are migraine headaches, fibromyalgia, arthritis, 
cancer pain, and that which results from traumatic injuries 
and degenerative disk disease. Table 4-1 shows the impact 
and extent of the problem caused by chronic pain. 



Defining the Program 



Table 4-10. 
Impact and Extent of Chronic Pain 



Number of Americans who have chronic pain 

Adults who routinely take prescription painkillers 

Number who can't do routine activities because of pain 

Proportion of employees who take time off from work because of pain 

Number of work days lost yearly to pain 

Annual loss in productivity due to pain 

Annual sales of over-the-counter analgesics 

Amount Americans spend annually on pain care 

Most common types of chronic pain that physicians treat 



48 million 

21.6 million 

13.6 million 

14% 

4 billion 

$65 million 

$3 billion 

$100 billion 

Cancer pain, 

lower back pain, 

arthritis, headaches, 

fibromyalgia 



Source: Wall Street Journal, October 18, 1999, p. R-6; National Institutes of Health; Louis Harris & Associates Inc. 



Because pain treatment providers vary so widely in their 
specialties, skills, and approach to pain management, the 
following questions may be helpful in defining the program: 

1 . What types of patients do you see and do you have a 
subspecialty in treating certain types of conditions? 

2. What is the patient flow after patients have checked in? 

3. Where does the initial history taking and interview 
take place? Who performs it? 

4. What is the frequency of visits or treatments for each 
type of patient and/or condition? 

5. Is anesthesia or conscious sedation used? 

6. What do the treatments consist of? 

7. What is the type of coordination with the patient's pri- 
mary-care provider, neurologist, neurosurgeon, physi- 



234 Medicine: Specialized Suites 



atrist (physician specializing in rehabilitation medi- 
cine), oncologist, rheumatologist? 

8. What type of recovery is generally required after treat- 
ment? If required, what is the length of stay in the 
recovery room? 

9. Is there any equipment used that requires specific or 
unique utilities? 



10. What is the ideal type of lighting in your examination 
and procedure rooms? Do you require a surgical light? 

The plan in Figure 4-152 was developed for an anes- 
thesiologist. It does not accommodate a massage thera- 
pist, psychologist, chiropractors, or others who sometimes 
work together in a coordinated, integrated approach to 
pain management. 



82' -0 




Figure 4-152. Space plan for pain management center, 2950 square feet. {Design: 
Jain Malkin Inc.) 



PAIN MANAGEMENT 



2950 SF 



Pain Management Center 235 




Types of Treatments 

There are many treatments for chronic pain such as phys- 
ical therapy, massage, chiropractic, electrical therapy, 
nerve injections and blocks, implantable pain devices, 
neuromuscular conditioning, biofeedback, and group and 
individual psychotherapy. 



Design Features 

People who suffer from chronic pain need a relaxing, 
comforting environment in which to receive medical treat- 
ment. Lighting is especially important. All attempts should 
be made to do away with 2-x4-foot fluorescent lighting in 
favor of indirect lighting around the perimeter of the room 
or from wall sconces or other semiconcealed sources. 

Temperature control is very important, especially in a 
biofeedback room, physical therapy room, or massage 
room. When patients are relaxing and/or undressed, if 
they are too warm or uncomfortably cold, their discomfort 
will defeat the treatment. With respect to the mechanical 
system, it is important to zone this suite very carefully and 
locate thermostatic controls in appropriate rooms. 

Depending on the types of specialists represented, the 
interior design of a pain management suite may run the 
gamut from clean and clinical, for suites that are more 
procedure oriented, to "New Age" — serene spaces with 
soft lighting, soothing music or nature sounds, perhaps a 
fountain, nonclinical style of furniture — reflecting the 
practitioners' desire to balance mind, body, and spirit. 



PSYCHIATRY 



1024 SF 



Figure 4-153. Space plan for psychiatry, 1024 square feet. (Design: Jain Malkin Inc.) 



PSYCHIATRY 

This is the easiest medical suite to design. The consulta- 
tion room is the key element in this suite. Each psychia- 
trist will have a preferred method of working, depending 
on his or her treatment philosophy. Some prefer a casual 
living room decor where doctor and patient sit next to 
each other in lounge chairs. Others offer the patient a 
sofa or chaise (Figure 4-153). Still others prefer a formal 



236 Medicine: Specialized Suites 



'PSY^UIATRY 




Figure 4-154. Schematic diagram of a psychiatry suite. 



directive approach, with the doctor behind the desk and 
the patient across from it. Those who practice hypnosis 
often choose to have the patient relax in a recliner chair 
that rocks back to elevate the patient's legs. 

Regardless of counseling style, the consultation room 
should be a minimum of 12X14 feet and preferably 
14X16 feet. Psychiatrists usually house their profession- 
al libraries in this room, so adequate bookshelf storage 
should be planned. Diplomas can be framed creatively 
and hung as artwork in the room. 

Some psychiatrists prefer a consultation room with a 
window; others find it distracting to the patient's concen- 
tration. Illumination should be rheostatically controlled so 
that it can be dimmed. 

Sometimes solo practitioners share an office suite. 
Each would need a consultation room, but the business 
office, waiting room, and group therapy room would be 
shared. There should be two or three seats per doctor in 
the waiting room. Since each psychiatrist can see only 
one patient per hour, this is a very low-volume specialty. 
The group therapy room should accommodate about 12 
persons. Chairs that stack are best, but they must be 



comfortable. The room should have a sink cabinet for 
preparation of coffee and perhaps a coat closet. 

Interior Design 

The waiting room may be residential in character. Patients 
are often nervous before therapy; thus, the waiting room 
ought to have a relaxing color palette and feel comfort- 
able, yet afford individuals some degree of privacy. Sound 
control is very important in this suite. All walls of consulta- 
tion rooms and the group therapy rooms should have 
sound-attenuating construction (see Chapter 14). 

The ambience of this suite is of utmost importance. 
Colors and design should be tranquil and serve as a 
background rather than be stimulating enough to be dis- 
tracting. Sharp contrasts in color or pattern should be 
avoided in favor of mellowness (Color Plate 21 , Figures 
4-1 55a and b). 

Table 4-11. 

Analysis of Program. 

Psychiatry 



No. of Physicians: 




1 






2 








3 




Exam Rooms 


14 


x 16 


= 224 


2@ 14 


x 16 


= 448 


3@ 


14 


x 16 


= 672 


Toilets 


7 


x 8 


= 56 


7 


x 8 


= 56 


2@ 


7 


x 8 


= 112 


Group Therapy 


16 


x 18 


= 288 


16 


x 18 


= 288 




16 


x 18 


= 288 


Staff Lounge 


10 


x 10 


= 100 


10 


x 10 


= 100 




10 


x 10 


= 100 


Business Office 


12 


X 14 


= 168 


12 


x 14 


= 168 




14 


x 16 


= 224 


Waiting Room 


12 


x 10 


= 120 


12 


x 10 


= 120 




12 


x 16 


= 192 


Storage 


4 


x 6 


= 24 


4 


x 6 


= 24 




6 


x 8 


= 48 


Subtotal 






980 ft 2 






1204 ft 2 








1636 ft 2 


15% Circulation 






147 






180 








245 


Total 






1127 ft 2 






1384 ft 2 








1881 ft 2 



Psychiatry 237 




Figure 4-156. Examination/observation room, child psychiatry. 
(Design: Jain Malkin Inc.; Photographer: John Christian.) 



Child Psychiatry 

Child psychiatrists prefer to observe patients in a natural 
setting, necessitating a room for play therapy. Typically, 
this room would have a one-way glass observation win- 
dow, a play table with chair or carpeted platforms, and an 
assortment of dolls, games, and other toys (Figure 
4-156). If an easel and paints are provided, a sink should 
be included in the room. An attractive cabinet may be 



designed to house all the toys in an orderly fashion. If 
appropriate space is available, a secured outdoor play 
area can be developed to allow the psychiatrist to study 
children playing naturally without their realizing they are 
being observed. 

The room in Figure 4-156 has been carefully designed 
for discreetly videotaping the child's activity, a necessary 
step for prosecuting child abuse offenders. 



UROLOGY 

A urologist treats diseases of the genitourinary tract. 
Thus, each patient must submit a urine specimen before 
being examined. The toilet room should be located close 
to the laboratory and have a specimen pass-through to 
the laboratory. Sometimes a toilet room is located 
between two exam rooms. Urologists perform most of 
their own lab work in the suite, and a minimum of 12 lin- 
eal feet of countertop should be provided in the laborato- 
ry. In addition, a solo practitioner would need two exami- 
nation rooms, at least two toilets, a cystoscopy (cysto) 



UQOLPCrf 




Figure 4-157. Schematic diagram of a urology suite. 



238 Medicine: Specialized Suites 




Figure 4-158. Cystoscopy table. (Photo courtesy: Hamilton Medical 
Furniture Corporation, Milwaukee, Wl.) 



room, a business office, a waiting room, and a consulta- 
tion room. This is a surgical specialty and therefore 
patients will have pre- and postsurgical consultations, 
which may occur in the urologist's private office or con- 
sultation room. Figure 4-157 shows the relationship of 
rooms. 

Patient flow is from the waiting room to the bathroom to 
the exam room and then to the cysto room, if necessary. 
The components of this suite are standard, with the 
exception of the cysto room. A patient with an inflamma- 
tion of the urinary bladder or prostate would be diag- 
nosed by a cystoscopic procedure to determine the pres- 
ence of an obstruction or an infection in the urinary tract. 



Cystoscopy 

In a cystoscopic procedure, the patient lies on a special- 
ized table (Figure 4-158) with feet placed in stirrups. The 
patient is usually lightly sedated with conscious sedation, 
perhaps Valium via an IV in the arm. An endoscope with 
fiber-optic light (and optional tiny camera) is inserted into 
the urethra to diagnose the problem. If the scope has a 
camera connected to a video monitor, the procedure can 
be viewed in real time and, with a printer, images can be 
captured for future reference. Men who have prostate can- 
cer or enlarged prostates, common as men age, routinely 
have this examination to monitor their conditions. Bladder 
tumors and kidney stones can also be discovered with this 
type of procedure. Sometimes the capacity of the bladder 



Table 4-12. 

Analysis of Program. 

Urology 



No. of Physicians: 








1 








2 








3 




Business Office 




12 


X 


14 


= 168 




16 


x 18 


= 288 




16 


X 20 = 


320 


Office Manager 




10 


X 


12 


= 120 




10 


X 12 


= 120 




10 


X 12 = 


120 


Waiting Room 




14 


X 


16 


= 224 




14 


X 20 


= 280 




14 


X 20 = 


280 


Toilets 


2@ 


7 


X 


8 


= 112 


3@ 


7 


x 8 


= 168 


3@ 


7 


X 8 = 


168 


Staff Lounge 




10 


X 


12 


= 120 




10 


X 12 


= 120 




12 


X 12 = 


144 


Storage 




6 


X 


8 


= 48 




6 


x 8 


= 48 




8 


X 8 = 


64 


Consultation Room 




12 


X 


12 


= 144 


2@ 


12 


X 12 


= 288 


3@ 


12 


X 12 = 


432 


Exam Rooms a 


2@ 


8 


X 


12 


= 192 


4@ 


8 


X 12 


= 384 


6@ 


8 


X 12 = 


576 


Nurse Station 




8 


X 


10 


= 80 




10 


X 10 


= 100 


2@ 


8 


X 10 = 


160 


Cysto/Exam (no X-Ray) 






— 






12 


X 12 


= 144 


2@ 


12 


X 12 = 


288 


Cysto (with X-Ray) b 




12 


X 24 


= 288 




12 


X 24 


= 288 




12 


X 24 = 


288 


Dressing Rooms 


2@ 




12 SF 


= 24 


2@ 




12 SF 


= 24 


4@ 




12SF = 


48 


Recovery 




6 


X 


8 


= 48 




8 


x 8 


= 64 




8 


x 8 = 


64 


Laboratory 




8 


X 


10 


= 80 




10 


x 10 


= 100 




10 


x 10 = 


100 


Subtotal 










1648 ft 2 








241 6 ft 2 








3052 ft 2 


20% Circulation 










330 








483 








610 


Total 










1978 ft 2 








2899 ft 2 








3662 ft 2 



a lf three exams per physician plus cysto rooms are required, as in Figure 4-159, suites will be larger, 
includes darkroom, control, film filing, and dressing cubicle. 



Urology 239 



71 -6" 




UROLOGY 



2288 SF 
Figure 4-159. Space plan for urology, 2288 square feet. {Design: Jain Malkin Inc.) 



is evaluated by inflating it with water. The cysto table has 
a tray to catch fluids that are voided during the procedure. 
A kick bucket on casters may also be used. Cysto rooms 
used to have ceramic tile floors and floor drains; however, 
current thought is that a floor drain can be a bacterial 
reservoir and should therefore be avoided. 

Certain procedures require X-rays. A urologist will typi- 
cally have a large cysto room for retrograde cystoscopic 
examinations (with X-rays) and a smaller room for cysto 
procedures not requiring X-rays (Figures 4-159 and 
4-160). X-rays are used for dye procedures. For example, 
dye introduced into each ureter allows the urologist to 



visualize the upper kidney tract to see a stone. Dye is also 
used to image bladder tumors, lodinated dye is used in a 
cystogram to show how a woman's bladder may have 
dropped downward with gravity. The patient's bladder is X- 
rayed while lying down (with the table flat) and in an 
upright position (Figure 4-158 shows exam table tilt). If the 
X-ray unit has fluoroscopy, the bladder can be imaged as 
it fills and empties to see the configuration of the bladder. 
After the procedure, the patient is able to get off of the 
table but may be a bit woozy or unstable as the sedation 
wears off. A recliner chair for brief recovery (Figure 4-159) 
is useful. Patients have to undress for this procedure. 



240 Medicine: Specialized Suites 



68-0" 



* 



o 
I 

CSI 



V- 




ENTRY 



UROLOGY 



2176 SF 
Figure 4-160. Space plan for urology, 2176 square feet. (Design: Jain Malkin Inc.) 



Urology 241 




Figure 4-161. Aura portable laser. 
{Photo courtesy: Laserscope, San 
Jose, CA.) 



Dressing rooms may be inside or outside the cysto room 
(Figures 4-159 and 4-160). It's important to have toilet 
rooms nearby as patients have the urge to urinate after 
the procedure. 



Design of the Cysto Room 

If designed to accommodate X-ray, the cysto room will 
have a darkroom, control area, and lead-shielded walls. 
The reader is referred to Chapter 3, Family Practice, for 
design of an X-ray room. The smaller cysto room can also 
be used for vasectomies, excisions of scrotal cysts, and 
minor surgical procedures. A portable laser may be used 
in this room (Figure 4-161). 

Good-quality sheet vinyl flooring with a self-coved base 
is recommended. A cysto room not equipped with X-ray 
may be as small as 11x12 or 12x12 feet. With X-ray, it 
will be about 12x24 feet, including the darkroom, and the 
room should have a 9-foot ceiling height. Open-shelf filing 
of X-ray films may be located in the corridor adjacent to 
the cysto rooms (Figures 4-159 and 4-160). Cysto rooms 
may have a 5-foot-high ceramic tile wainscot on all walls 
or other easily cleaned surfaces, and may have a wall- 
mounted urinal. (There is a strong urge to urinate after a 
cystoscopic procedure.) Furthermore, the room should 
have an exhaust fan. The examination table used in this 
room is pictured in Figure 4-158. 

It should be noted that the X-ray film plate pulls out 
from the right side of the table; therefore, the optimal lay- 
out of the room would place the table with ample room on 
the right side, which should also be closest to the dark- 
room (Figures 4-159 and 4-160). The sink cabinet would 
be to the left of the patient. 



Lab 

The lab is used for semen examination and for simple dip- 
stick tests such as urinalysis to measure sugar or blood 



in urine, or to measure pH. A centrifuge on the counter 
would be used to spin-down blood. An undercounter 
refrigerator and a sink are required. A specimen pass- 
through in the wall between the lab and toilet prevents 
patients from having to carry a urine specimen through 
the corridor. The lab may have a CRT and printer for run- 
ning off labels for urine or blood specimens. 



Nurse Station 

The nurse station is typical in this specialty. It will have a 
wet area with sink and an autoclave for sterilizing instru- 
ments (many of which are reusable) and a "dry" area for 
charting and making phone calls. Storage for frequently 
used forms and for instruments, a CRT for receiving lab 
results, and an undercounter refrigerator are also 
required. 



Interior Design 

Because this is a surgical specialty, physicians often run 
late, necessitating a larger than average waiting room. In 
addition, many elderly patients are accompanied by a 
spouse or escort. 

There are no special requirements in this specialty in 
terms of interior design. However, there are some urolo- 
gists who have built a large practice in a subspecialty, 
namely, male sexual dysfunction. If this is the case, one 
may want to design the suite in a more masculine style, 
perhaps using artwork with a Western theme or a sports 
or hunting theme. 

As regards finishes, the walls and floors of cysto rooms 
must be easily cleanable. Exam rooms should not have 
carpet. A wood-look sheet vinyl like Toli® is functional as 
well as aesthetically appealing. Note that the recovery 
room should have hard-surface flooring as the urge to uri- 
nate frequently is strong after cysto procedures. A rest- 
room should be nearby. 



242 Medicine: Specialized Suites 



CHAPTER 5 



Diagnostic Medicine 



Author's Note: Writing this chapter has been a challenge in 
that digital imaging at this moment is a work in progress 
and, to describe it, is somewhat akin to shooting at a mov- 
ing target. I gathered information from many sources to 
educate myself about the topic so that I could explain it to 
others. I contacted knowledgeable sources representing 
five perspectives: an architect friend and colleague whose 
expertise and passion about diagnostic imaging is well 
known; manufacturers, who understandably are proud of 
their new products and anxious to promote them; chief 
technicians with 20 to 30 years of experience installing a 
variety of imaging modalities and systems during their 
employment with major equipment manufacturers; region- 
al vendors of X-ray equipment, accessories, and supplies; 
and radiologists. All of these resources have experience 
with film-based as well as digital imaging, realizing, how- 
ever, that the latter is still in its infancy. What has been vex- 
ing is the difference of opinion on how quickly digital imag- 
ing will overtake the industry; the reliability of the 
interface — called DICOM compatibility — between equip- 
ment by different manufacturers; and what the final digital 
imaging system will look like 5 or 10 years from now when, 
one would assume, film has gone the way of the horse and 
buggy and a darkroom can only be found in the studio of a 
fine-art photographer. 

My architect friend, who works for a national architectur- 
al firm and often plans diagnostic imaging departments for 
academic medical centers and 250,000-square-foot ambu- 
latory-care centers, suggested that references to film and 
darkrooms should be cut to an absolute minimum, that in a 
very brief period one will not find even a view box illumina- 
tor in most settings. I got a different picture, however, from 
several radiologists I interviewed and from regional vendors 



of equipment and supplies. A number of the vendors said 
they are selling as much film now as they did five years ago 
and the conversion to digital will happen more slowly than 
some estimate because the financial analysis has to be 
favorable to enable radiologists to make the conversion, 
which, of course, involves many factors. If reimbursement 
for orthopedic films is low and since digital radiography 
equipment costs considerably more, the number of proce- 
dures one could feasibly do within the workday may provide 
a poor return on investment, although one also has to factor 
in the expectation that digital imaging enables higher 
throughput (patient volume) than a film-based machine. 

Although most radiologists recognize the value of ulti- 
mately converting to a totally digital system, which will 
enable them to send and retrieve images over a network 
throughout the enterprise, they are dealing with the tremen- 
dous financial commitment as well as the risk of selecting 
the best manufacturers to partner with whose systems will 
ultimately prove to be the most reliable and the most flexible 
as the technology evolves. I also received a lot of practical 
tips and advice from the technical experts who are charged 
with installing the equipment and systems, keeping it main- 
tained, and troubleshooting when there are problems. 
Oblivious to the marketing hype of "how DICOM compatible 
every item is," they will tell you that a lot of black boxes (elec- 
tronic pieces of equipment that create an interface between 
non-DICOM-compatible items), switches, patch panels, and 
converters are required to make it all work at the current 
time. Clearly, this industry is changing rapidly and the 
plethora of products introduced every couple of weeks to 
manage and store digital data is staggering. As in any field 
when rapid change takes place, eventually a number of lead- 
ing products emerge, while others fall by the wayside. What 



243 



I've presented in this chapter represents all the viewpoints 
I've heard from respected sources and I've tried to present an 
unbiased view of the industry today. However, I was limited as 
to the number of equipment photos I could use and I regret I 
could not include selections from all major manufacturers. 

I was pleasantly surprised to see, compared with 10 
years ago when the second edition of this book was writ- 



ten, how dramatically product design has improved. Every 
manufacturer has CT, MR, and nuclear imaging equipment 
that is so sleek and sculptural — which is hard to imagine 
for items of such large mass and weight. Compared to 
equipment available 10 years ago, it seems as if design 
and aesthetics were not even factored into the equation at 
that time. 



DIAGNOSTIC IMAGING 

What's new in diagnostic imaging? Everything. Nowhere 
in healthcare has the digital revolution had more impact. 
The goal is seamless transfer of images throughout the 
enterprise — total connectivity among physicians, radiol- 
ogists, and hospitals. Referring physicians and special- 
ists who previously had to wait many hours to several 
days for a film to be retrieved and delivered now have 
instant access to patient information. No misplaced or 
lost films; no need to carry films from one location to 
another; elimination of X-ray retakes (exposing the 
patient to more radiation) to compensate for errors in 
technique; and elimination of the cost of film. Of course, 
to accomplish this massive undertaking, eventually all 
diagnostic imaging equipment has to be digital so that 
images go directly to a network where they can be 
reviewed, analyzed, distributed, and, ultimately, stored. 
GE's PathSpeed™ is an example of a PACS (Picture 
Archiving Communication System) that manages data. 
Many manufacturers are developing PACS, each offering 
certain commonalities as well as distinctive proprietary 
features to give them a marketing edge. Once one 
recovers from the trauma of conversion from film to dig- 
ital, the day-to-day ease and speed of working with 
images on a monitor, and being able to send an image 
to a remote specialist for consultation (by a teleradiology 
connection), no doubt the expense and discomfort of 
learning and mastering a new system will be justified. 
Certainly, there are various steps that can be taken to 
ease into a fully digital work environment. The easiest 



conversions, of course, are CT and MRI because they 
are digital modalities to begin with. Ultrasound is also 
digital, which leaves — in the basic radiology suite — a 
general radiography room, a radiography and fluo- 
roscopy (R/F) room, and mammography. As new equip- 
ment is purchased, these investments will most likely be 
digital and, over time, the entire enterprise will be a total- 
ly integrated digital environment. 



Goal: Acquiring Better Diagnostic 
Information in Less Time 

The overarching goal in the transformation from 
analog/film images to digital is the hope of acquiring bet- 
ter diagnostic information in less time. Conventional X-ray 
film and chemicals are being replaced by silicon detec- 
tors and images that are displayed almost instantaneous- 
ly on a high-resolution monitor. With such systems, a 
physician is able to send an image electronically to col- 
leagues for discussion and evaluation in real time, all 
looking at the same image on their respective monitors. 
Currently, pulling a reference film from five years ago to 
compare it with a new one can be a challenge, requiring the 
time of a file clerk to find it and someone to transport it to 
the referring physician or radiologist, and then reversing the 
process to get it back to the hospital. Many steps, many 
people. Ideally, when hospital images are all digital and 
there is total interconnectivity within the enterprise, the 
images should be available within moments, rather than 
days or weeks. The overall goal is not just to move film 



244 Diagnostic Medicine 



images, but to integrate them with patients' laboratory test 
results and the electronic medical record and, with powerful 
databases, to code procedures for processing insurance 
claims, send reports and thumbnail images to referring 
physicians, and offer to rural medical centers and clinics the 
expertise of radiologists at distant major medical centers. 

The new diagnostic imaging equipment showcased at 
RSNA (the Radiological Society of North America) each 
November is often startling in its innovation. Perhaps 
responding to a somewhat flat market for certain imaging 
modalities, manufacturers seem to have recently worked 
diligently to differentiate their products, especially true in 
CT, MRI, and a hybrid CT/PET (positron emission tomog- 
raphy) that is truly an astounding accomplishment. For 
those who may not be familiar with it, RSNA is "Mecca" 
for anyone associated with any aspect of diagnostic 
imaging. Held each November or December at 
McCormick Place in Chicago, it attracts 65,000 attendees 
worldwide. Magazines like Diagnostic Imaging and 
Medical Imaging publish a preview issue prior to the 
event and a new product review afterward, both of which 
are very informative. 



PACS 

Picture Archiving Communication Systems are being 
developed to manage digital data and images. Each ven- 
dor offers somewhat different system design, user-friend- 
ly interface, and certain proprietary features. PACS is a 
generic term for these data acquisition and image man- 
agement systems, which generally have the following four 
components: image acquisition, image storage, image 
transfer (over a network), and image retrieval. PACS 
refers, in a generic sense, to any electronic substitute for 
film, but PACS can be based on direct ray (DR)* transfer 
of images or computerized radiography (CR), which is 
explained below. PACS may further be defined, according 
to Data General, as: 



*lt should be noted that DR, as a term, is interchangeably used to refer to direct 
ray, digital radiography, and direct radiography. 



• Mini-PACS — connecting single or multiple imaging 
modalities using viewing stations with or without soft 
reading and/or digital storage archiving. 

• Full PACS — connecting all modalities, viewing/reading 
soft copy/enlarged digital storage. It is integrated with 
both the hospital and the radiology information sys- 
tems and distributes data and images throughout the 
healthcare network. 

• Teleradiology — connecting the radiology service to 
the radiologist's home, emergency department, inten- 
sive-care unit, or rural clinics. 

Computed Radiography 

Computed radiography (CR) is a more advanced form of 
radiography that uses electronic media instead of film. 
The cassettes typically look like standard film cassettes 
but they don't have film in them; they have a phosphor 
plate that records the image and gets reused. The tech 
takes the plate out of the unit and puts it in a plate read- 
er, which reads the image and simultaneously erases the 
plate for reuse. This has several additional workflow steps 
associated with it compared with a more direct method of 
recording the image. The image that has been read is 
stored on an internal hard drive, which can then send the 
image to a PACS or print it on paper or film. 

Direct Radiography 

Direct radiography (DR) bypasses the phosphor plate; it 
is a direct transfer of the image to a PACS. One can 
potentially do many more procedures per room because 
the tech has fewer workflow steps. Presently, DR is con- 
siderably more expensive and the "Holy Grail" for the 
future will be less expensive direct-transfer systems. 

Converting Film to Digital Images 

There are several ways of transitioning from film to a dig- 
ital system and the major radiographic equipment manu- 
facturers have recognized the need for a transitional strat- 
egy to help make this conversion by developing systems 
that achieve filmless imaging in phases, over a period of 
time, working with existing diagnostic equipment. 



Diagnostic Imaging 245 



There are several methods of converting film to digital 
images: One can take the X-ray and digitize it; images 
from modalities that cannot output digitally can be con- 
verted into digital images by video capture systems (mul- 
tifrequency video capture boards installed in PC con- 
trollers can be equipped with barcode readers to facilitate 
quick entry of patient details and identification data). 

DICOM Compatibility 

Most manufacturers are making products that are DICOM 
compatible, which facilitates interconnectivity among 
pieces of equipment purchased from different vendors 
and assures that all images will reach the server without 
degradation or loss. Digital Imaging and Communications 
in Medicine (DICOM) is the standard for compliance 
developed by the American College of Radiology and the 
National Electrical Manufacturers Association. DICOM 
provides a format for how files are created to make it pos- 
sible to move information from one system to another. 
The goal is total interface among the equipment of vari- 
ous manufacturers. 

Image Storage 

It is a challenge to keep pace with the vast amounts of 
graphical data (radiographic images) and the need for 
short-term and long-term storage, as well as quick 
retrieval of old files to compare with new imaging studies 
for a specific patient. Data may be stored in a main serv- 
er with storage capacity enhanced by RAID (redundant 
arrays of inexpensive disks), which provides more imme- 
diate-access on-line data. On-line storage of images — 
perhaps 30 to 90 days of studies — would be on the RAID 
(although it is possible to configure a RAID-centric PACS 
model to accommodate more than a year's studies avail- 
able on line). From there, they will likely go to near-line 
storage, which may constitute a 6- to 12-month period, 
and this storage may be on an ultra-high-capacity tape or 
digital videodisc (DVD) library or "jukebox." After that, 
images would go to off-line storage for long-term archiv- 
ing. It should be noted that the library or jukebox relies on 
a mechanical process to locate the proper piece of media 
and load it into the drive in order to retrieve the data. 



DVDs hold much more data than CDs (compact discs) 
and offer 30 to 50 years' shelf life. Realizing the size of 
these graphical files, which must handle large images, 
the demand for large memory configurations and vast 
storage capacity is staggering. To be able to store and 
retrieve such large amounts of data in a matter of sec- 
onds requires high-speed, broadband networks and high- 
resolution displays. Jukebox technologies may be optical, 
DVD, tape, or CD. These are designed for mass storage 
of data. A rack (Figure 5-1), located in a secure storage 
room, can hold the UPS (uninterrupted power source), 




Figure 5-1. Mass-storage unit/archive library for radiologic images. 
(Photo courtesy: Rorke Data, Eden Prairie, MN, a subsidiary of Bell 
Microproducts, Inc.) 



246 Diagnostic Medicine 



RAID, server, and long-term archive library. Multiple 
archival libraries can be connected using pass-through 
technology. Images move from on line (the server) to near 
line (the jukebox or archival library), and then off line, 
which may be in a remote location. Redundancies are 
built into all of these archiving systems to account for 
power failures, loss of data, fire, and so forth. Some PACS 
are designed to automatically route data, at certain 
preestablished intervals, to three to five redundant stor- 
age locations. Of course, the cost of storage media is a 
large contributor to total costs. Optical storage, also 
known as MOD Magneto Optical Storage, is a disk read 
by laser and considered the most reliable for long-term 
storage but is currently the most expensive. 

Jukeboxes or archive libraries must be placed in a 
secure, restricted-access, storage room, which may be 
within the facility or located remotely. There are no special 
HVAC requirements for this room as the storage "racks" 
have internal cooling fans. Some are accessed only from 
the front, others from the rear, but none should be placed 
too close to a wall as there is considerable cabling and 
one must have access to it for maintenance. Once a 
library archive or jukebox is operational, it cannot easily 
be moved. 

Data Storage. Off-line images and data can be stored in 
large data repositories and "warehouses," the digital 
equivalent of sending aged medical charts to a Beacon's 
warehouse for storage. 

For hybrid suites, there will still be a need for conven- 
tional film filing, discussed later in this chapter. For a fully 
digital operation, film filing is replaced by a room for the 
server and archives (jukebox) although, theoretically, the 
jukeboxes (and even the server) may be at a remote loca- 
tion. Film files used to require a tremendous commitment 
of space, whereas now perhaps a room 10x12 feet may 
store 1 years of data. 

Application Service Provider 

It should be noted that the PACS can be outsourced to an 
application service provider (ASP). This represents a way 
of financing the endeavor, which, much like lease pay- 



ments, comes out of an operating budget rather than cap- 
ital investment. And, much like a lease, as equipment 
becomes obsolete it is replaced because the equipment 
is owned by the ASP. This option is often priced on a per- 
patient (procedure) basis. 

ASPs grew out of the recognition that financing the 
conversion to digital imaging out of capital budgets con- 
stituted a big hurdle for many organizations. There is 
great variety in what ASPs offer. Basically, they buy soft- 
ware and hardware from a variety of vendors and cus- 
tomize a system to meet an individual enterprise's needs. 
Some of these are proprietary models that use Web- 
based architecture to enable a number of data and image 
management tasks to be executed from scheduling and 
registering patients to processing and interpreting diag- 
nostic studies to archiving images to distributing these 
data to referring physicians. 



Getting from Here to There 

The challenge in writing this chapter is that it needs to 
reflect the hybrid nature of what designers will be encoun- 
tering whether designing a one-room radiology suite for 
an orthopedist or general practitioner or a radiology suite 
in a medical office building. The focus of the discussion, 
and the market for this book, is the non-hospital-based 
facility, which, in this case, means a radiology suite that 
serves tenants in a medical office building or that may be 
freestanding. A recent trend in some regions of the nation 
is the freestanding radiology enterprise that contracts 
with physicians and hospitals. It frees hospitals from hav- 
ing to make an investment in expensive equipment, keep 
it maintained, and employ technical staff. Although it 
would seem cumbersome and costly to transport inpa- 
tients to an off-site facility, apparently this is occurring in 
some regions. 

The hybrid nature of what an architect might encounter 
implies that there will be some film-based modalities and 
others that are digital within the same facility. In this case, 
a conventional darkroom, or daylight processors, will be 
needed, or a dry view laser imager may be used for CT 



Diagnostic Imaging 247 



or MRI, which requires no darkroom, or one may 
encounter a new, fully digital environment. As reliable 
sources differ in their forecasts of when all imaging 
equipment will be filmless, this chapter will, of necessity, 
address all of the above. 



Conventional Radiology 

General principles are commonly understood. A limb is 
exposed to X-rays, which penetrate body tissues, expos- 
ing film mounted on a cassette (film holder) positioned on 
the other side of the limb. Since body tissues absorb dif- 
ferent amounts of radiation, bones, fat, gas, and so on 
make different exposures compared with surrounding tis- 
sues, which allows the observation of internal body parts 
without pain and with small exposures to radiation. 

In addition to examination of limbs, diagnostic imaging 
is used to diagnose the presence of gallstones and kid- 
ney stones, tuberculosis, arthritis, and bone tumors; to 
discover foreign bodies in soft tissue; to detect enlarged 
or malfunctioning glands; to scan the brain; to reduce 
tumors (radiation oncology); to monitor a child in the 
womb (ultrasound); and to diagnose scores of other dis- 
eases. Some forms of diagnostic imaging, such as ultra- 
sound, do not involve radiation. 

Making an X-ray film of a leg or the chest requires no 
special preparation, but filming organs such as the gall- 
bladder or the gastrointestinal tract requires that the 
patient fast before the procedure and then drink a special 
liquid or receive an injection that makes the organs visi- 
ble to the radiologist. Since the designer must understand 
these procedures in order to plan an efficient suite, a brief 
outline of diagnostic radiology modalities follows. 



Diagnostic Imaging Modalities 



Fluoroscopy 

Fluoroscopy enables the radiologist to watch internal body 
structures at work. The patient swallows or receives an 



injection of a contrast medium — air, barium sulfate, or 
organic iodine compounds — which causes the soft-tissue 
systems of the body to be outlined. X-rays passed 
through the body strike the input phosphor of an image 
intensifier tube, and that image is intensified electronical- 
ly and can be viewed on a TV monitor. (TV monitors may 
be ceiling or wall mounted, or portable, on the floor.) Hard 
copies (X-ray films) can be made at this time. With a video 
camera, screen images can be converted into real-time 
studies for future reference. 

A contrast medium injected into a blood vessel 
(angiography) travels with the blood supply to a specific 
organ and allows the radiologist to examine that organ. 
For a study of the large intestine, a patient is given a bar- 
ium enema. The radiologist makes sequential spot film 
(or digital) radiographs while the barium travels through 
the large intestine. To study the digestive system, a 
patient drinks barium and the radiologist films it traveling 
down the esophagus into the stomach, following it 
through the small intestine. Of course, endoscopy has 
greatly reduced the number of gastrointestinal barium 
studies. 

Digital fluoroscopy is the technique for converting X- 
rays into visible images without film. Photographic film is 
replaced by an electronic image tube that produces a 
direct image of a broken bone, lung, brain, or other body 
organ being studied. This eliminates photographic pro- 
cessing. 

Ultrasound 

Ultrasound does not involve radiation. A high-frequency 
sound, much like sonar, bounces off internal body struc- 
tures. Ultrasound is particularly useful in examining soft 
pelvic tissue masses, gallbladders, or a fetus in the worn 
— procedures where even low doses of radiation might 
be dangerous. Ultrasound is also commonly used to 
image the heart (echocardiography) and for studies of 
blood flow in arteries and blood vessels. It is commonly 
used to analyze suspicious breast lesions, and tissue 
can also be biopsied using ultrasound. Physicians who 
do in vitro fertilization use ultrasound routinely during a 
variety of procedures. 



248 Diagnostic Medicine 



Nuclear Medicine 

Nuclear medicine deals with the diagnosis and treatment 
of disease with radioactive isotopes — chemicals that are 
unstable and break down, giving off radioactivity. The iso- 
tope may be given to the patient orally or by intravenous 
injection. The substance is specific to a particular gland or 
organ (e.g., iodine travels to the thyroid gland). The 
amount of the isotope absorbed by the gland permits the 
radiologist to determine the function of the organ and to 
trace its outline. Nuclear scans are useful for diagnosing 
brain tumors and malfunctioning of the kidneys, pan- 
creas, and thyroid. Positron emission tomography (PET) 
scanners are considered one of the best modalities for 
detecting cancer lesions. One of the most stunning 
advances in technology is the CT/PET combination, 
which allows a fusion of CT's rendering of anatomy with 
PET's imaging of critical metabolic processes. 

Computed Tomography 

Computed tomography (CT) allows physicians to see 
cross sections of internal body structures, enabling the 
radiologist to discover tumors embedded in soft tissue or 
organs that formerly could not be seen by radiographic 
procedures. Thus, CT scans have eliminated much 
exploratory surgery and offer the patient greater safety by 
reducing the need for more dangerous, often painful, 
tests. 

The patient lies on a table that slides through a rotating 
doughnut-like enclosure called the gantry. X-rays scan 
narrow cross sections of the body in a painless, noninva- 
sive procedure. For example, 180 scans just 1 degree 
apart may be taken of an area. The numerous images are 
collected by a detector and reconstructed by a computer 
into a composite scan of the organ or tissue. CT scanners 
represented a major breakthrough in diagnostic imaging 
technology when they were introduced in 1977. The 
newest CT scanners are multislice, six times faster than 
traditional single-slice scanners. During the scan, three- 
dimensional (3-D) images are built in real time and are 
completely constructed by the time the scan ends. 
Potential future uses include measurement of cerebral 
blood volume and flow, used in evaluation of stroke. 



Mammography 

Low-dose mammography, an X-ray of the breast, is con- 
sidered to be the most accurate and safe means of 
detecting breast cancer at an early, usually curable stage. 
The American Cancer Society claims that 1 out of 10 
women in the United States will get breast cancer at 
some point in her life. Therefore, screening mammogra- 
phies are recommended on a regular basis for women 
over the age of 40 and perhaps even earlier for those who 
have a family history of breast cancer. As of this writing, 
mammography is more commonly film based, although 
the Food and Drug Administration (FDA) recently 
approved a full-field digital mammography system. 

Radiation Oncology 

Through use of a linear accelerator, tumors are bom- 
barded by very narrowly focused, high doses of radiation 
in an attempt to kill cancer cells. The course of treatment 
is carefully plotted and monitored by a radiation physicist 
and the radiology team. The normal course of treatment 
runs six weeks, during which time the patient reports five 
times per week. 

Magnetic Resonance Imaging 

Magnetic resonance imaging (MRI) has been heralded as 
a major innovation in diagnostic imaging and, today, it 
represents 20 percent of the medical imaging market, 
according to Medical Imaging magazine. It provides 
exceptional soft-tissue contrast and is especially good for 
imaging the central nervous system and, in particular, the 
brain. It permits early and accurate diagnosis of a wide 
variety of conditions, including brain tumors, strokes, 
hemorrhage, and multiple sclerosis. Spinal cord com- 
pression is more effectively shown by MRI than by other 
imaging techniques. A pinched nerve or the effects of 
arthritis can be graphically demonstrated and may pre- 
vent the need for a myelogram or CT study. MRI is also 
effective for diagnosing knee injuries and cancers of the 
musculoskeletal system. 

MRI does not use X-rays, but rather depends on the 
interaction of radio waves and small particles within the 
body, called protons, in the presence of a strong magnet- 



Diagnostic Imaging 249 



ic field generated by the MRI equipment. A simplified 
explanation of a very complex process follows. 

Inside the body, protons absorb energy from incoming 
radio waves of various frequencies and, in turn, give off 
energy in the form of radio waves. These outgoing signals 
are recorded by a highly sophisticated computer and 
reconstructed into an image similar to that produced by 
CT, but generally with higher resolution, showing more 
detail and an enhanced view of diseased tissues. 

Advantages to the patient are that no special prepara- 
tions are required before the procedure, no injections of 
contrast media are generally required, and it does not use 
radiation. Although currently MRI examinations are 
expensive and take longer than a similar CT procedure, 
this may change as the technology advances. Other 
applications of MRI include in vivo spectroscopy and 
study of living tissues, providing information on process- 
es occurring inside the cell. A single example of the 
derived benefit of this is diagnosing a tumor without 
resorting to biopsy, based on the fact that tumors are 
known to affect cell metabolism. There are many applica- 
tions of MRI continually in development. 



Planning Considerations 

The purpose of this chapter is to introduce the reader to 
the most common diagnostic imaging modalities and to 
explain the general parameters of designing rooms to 
accommodate this equipment. Clearly, one could write 
an entire chapter on each of the modalities if one want- 
ed to cover thoroughly all aspects of design and con- 
struction. The focus of this discussion is the outpatient 
radiology facility that would commonly be found in a 
medical office building, as opposed to one located with- 
in a hospital. 

Before a space planner can begin to lay out the suite, 
a program must be developed. There is a difference in 
how this is accomplished when the client is an inde- 
pendent radiology group developing a tenant space in an 
MOB versus a client that represents a radiology depart- 
ment that will serve a 250,000-square-foot ambulatory- 



care center affiliated with a hospital. In the former case, 
the radiology group will generally detail for the space 
planner the number and type of diagnostic imaging 
rooms that will comprise the suite. There is no way a 
space planner can second-guess this, as it depends on 
a number of considerations. First, if the radiology group 
has CT at another office not too far away, it's unlikely 
they will duplicate this equipment. Second, the number of 
physician tenants in the building and their respective 
specialties will influence the type of equipment the radi- 
ologists buy. Third, the medical building's proximity to a 
hospital and the type of imaging modalities available at 
the hospital may influence the selection of equipment for 
the facility, especially if the same radiology group staffs 
the department at the hospital. 

In the other example (the radiology department serv- 
ing a large ambulatory center), the programming will be 
done by the architect or planner who will do workload 
analysis to determine the number and type of procedure 
rooms required. This must be done in collaboration with 
the radiologists as throughput (volume on each imaging 
modality) will be influenced by decisions to purchase 
new equipment and the extent of overall digital integra- 
tion in the enterprise. If the medical center with which 
the ambulatory facility is affiliated has a high-profile car- 
diology, oncology, or neurosciences center, a high 
enough volume of patients in one of these areas may 
warrant the purchase of specialized imaging equipment. 
All of these issues must be considered and factored into 
the workload analysis and ultimate program that is 
developed. 

These are the six basic planning considerations: 

1. Equipment 

2. Patient flow 

3. Staff flow 

4. Information flow 

5. Function 

6. Flexibility 



250 Diagnostic Medicine 



Equipment 

A number of manufacturers offer equipment for each 
imaging modality. Room size and critical dimensions vary 
considerably, as do utility requirements. There are numer- 
ous accessory or ancillary items that may be added to 
each major piece of equipment. The space planner, there- 
fore, may be faced with a number of possible combina- 
tions of equipment for an individual room. The radiologist 
will make these selections, but the space planner must 
obtain from each manufacturer a planning guide and 
specifications for each unit. Clearly, equipment dictates 
the size of each room, with function and future require- 
ments being the two important considerations. It should be 
noted that manufacturers usually offer planning services 
to lay out a department and often produce almost a full set 
of construction documents. One must remember, howev- 
er, that their goal is to sell equipment and to make sure it 
fits in the room. These services should be relied on only to 
provide technical assistance to the space planner or archi- 
tect, who is much more likely to produce a functional lay- 
out that considers overall patient flow, business office 
activities, and the relationship of each room to the whole. 
When equipment is placed in the room, function is 
achieved when proper clearances are preserved for items 
that swivel, extend, or tilt and for travel of the tabletop. 
Other aspects of function are patient access and staff 
ability to move around the room (e.g., if a patient needs 
to be transferred from a stretcher or gurney alongside the 
X-ray tabletop). Finally, each procedure room must have 
an area within it, or outside of it, for controls. Within the 
room, the control area is a lead-lined partition with a win- 
dow in it. The tech stands behind it to operate the gener- 
ator that controls the equipment in a film-based set-up. 
Note that the window must have a minimum 18 inches of 
wall on the leading or open end to protect the tech. The 
control unit is not very large as shown in Figures 5-3 and 
5-4; however, in a digital set-up, the control room is some- 
what larger and will have a stand-up- or sit-down-height 
countertop approximately 4 feet wide for the operator's 
control console in addition to a quality-control computer, 
which, in the future, may be integrated into one unit 
(Figures 5-7, 5-8, and 5-10). 



It is optimal, when designing major radiography or radi- 
ography/fluoroscopy rooms (abbreviated R&F or R/F), to 
size them generously in order to accommodate future 
technology and anticipation of more interventional proce- 
dures requiring more staff. Radiographic rooms are very 
expensive to remodel due to lead shielding and other 
construction features. 

Patient Flow 

The overall layout of the radiology suite is driven by a 
desire to separate patient circulation from the staff work 
area (Figure 5-2). In Figures 5-3 and 5-4, patient dress- 




DDOaOODDOODC) PATIENT CIRCULATION 
initialing STAFr CIRCULATION 

FUNCTIONAL RELATIONSHIPS 

Figure 5-2. Functional relationships, diagnostic imaging. 



Diagnostic Imaging 251 



Table 5-1. 

Analysis of Program. 

Diagnostic Imaging 



No. of Physicians on Site: 


1-2 






2-3 




Waiting Room 


14 x 18 


= 252 




16 X18 


= 288 


Women's Center, Sub-waiting 3 


10 X 12 


= 120 




10 X12 


= 120 


Business Office 


14 X 16 


= 224 




16 X20 


= 320 


Dressing Cubicles 6@ 


4X4 


=96 10® 


4 


X 4 = 


160 


Handicapped 


6X7 


= 42 


2@ 


6X7 


= 84 


General Radiography 


14 X 16 


= 224 




14 X16 


= 224 


Radiography/Fluoroscopy 


16 x 18 


= 288 


2@ 


16 X18 


= 576 


Toilet 


7X8 


= 56 


2@ 


7X8 


= 112 


Ultrasound 


10 X 12 


= 120 




10 X12 


= 120 


Mammography 2@ 


10 X 12 


= 240 


2@ 


10 X12 


= 240 


Nuclear Medicine 


— 










Hot Lab 


— 






6X8 


= 48 


Procedure Room 


— 






16 X19 


= 304 


Patient Prep 


— 






8 X10 


= 80 


Sub-Waiting 


— 






10 X12 


= 120 


Toilet 


— 






7X8 


= 56 


CT Scanner Suite* 


— 






14 X28 


= 392 


MRI Suite 


— 






23 X51 


= 1173 


Toilets 3@ 


7X8 


= 168 


5@ 


7X8 


= 280 


Darkroom/Processing (optional) 


10 x 10 


= 100 




10 X12 


= 120 


Tech Work Area 


Varies 


120 




Varies 


150 


Film Filing (Optional) d 


Varies 


300 




Varies 


400 


Private Office (Radiologist) 


12 x 12 


= 144 


2@ 


12 X12 


= 288 


Administrator 


10 x 12 


= 120 




10 X12 


= 120 


Physicians' Viewing Area 


6X8 


= 48 




6X8 


= 48 


Storage 


8X10 


= 80 




8 X10 


= 80 


Staff Lounge 


12 x 16 


= 192 




14 X16 


= 224 


Subtotal 




2934 ft 2 






6127 ft 2 


25% Circulation 




733 






1532 


Total 




3667 ft 2 






7659 ft 2 



"Optional 

includes procedure room and control room. 

includes procedure room, control, and electronic equipment room; layouts and room sizes vary per 
manufacturer and model/type of magnet. 

d lf totally digital, a film filing area is not needed; an on-site storage room for the digital library and data 
communications equipment would replace it (requiring much less space). 

Note: The above sizes are an approximation, since radiography rooms must also have control areas, 
which may be inside or outside the room. Many radiologists will have both a private office and a read- 
ing room, while others may share a private office. There are many variables, depending on whether 
the radiologists rotate among several locations or remain at one. Tech work areas will vary in a digital 
versus film-based setting. 



ing rooms are toward the front of the suite but also near 
procedure rooms. Patients circulate around one side of 
the procedure rooms, while the staff work corridor is on 
the other side of those rooms in Figures 5-4 and 5-5. 
However, it is not always possible to do this (Figure 5-3). 
The staff work area includes film (if used) processing, 
film (or digital image) reading, tech sorting (if film based) 
and viewing area, staff lounge and restrooms, and radi- 
ologists' private offices. In Figure 5-5, the control area for 
each procedure room is outside the room in the control 
corridor. This suite plan keeps patients out of staff work 
areas and, additionally, prevents them from overhearing 
staff conversations and from casually seeing X-ray films 
on view boxes in the tech area. It is desirable to protect 
the patient from overhearing or seeing anything that 
might cause anxiety or discomfort or constitute a breach 
of privacy. This has also been accomplished in the 
breast center plan in Figure 4-19. In Figure 5-4, the con- 
trol areas are within the procedure rooms. Film cas- 
settes are passed back and forth to the darkroom by 
cassette pass boxes in the wall. If Figure 5-4 were to be 
all digital, the area where the darkroom is located would 
be the control console, the view box illuminators would 
not be needed, and the "film" reading room would have, 
in addition to a conventional view box illuminator, a 
PACS monitor(s) for reading and interpreting images 
(Figure 5-6). There may be an additional viewing station 
(Figure 5-7) designed for passive viewing and for send- 
ing and receiving images to remote locations. This view- 
ing station may also be used by referring physicians in 
the medical office building who may not be set up in 
their offices to receive this type of data. 

The suite in Figure 5-5 separates traffic to the women's 
center, which is typically a high-volume unit. The sub- 
waiting area is dedicated to the women's center. This unit 
functions independently from the rest of the suite and has 
its own daylight film processor located in the tech work 
area. In Figure 5-4, a mammography room with a private 
entry vestibule accommodates patients of a neighboring 
OB-GYN office. 



252 Diagnostic Medicine 



62-0 




RADIOLOGY 



3906 SF 
Figure 5-3. Space plan for radiology, 3906 square feet. (Design: Jain Malkin Inc.) 



Diagnostic Imaging 253 



72-0" 



-»*- 




MAMMOGRAPHY 



i PROC. i 

i i 



I 1 WOMEN'S CENTER 
1 1 ENTRY 



□QQ 



DRESS 



DRESS 



RADIOLOGY 



3168 SF 
Figure 5-4. Space plan for radiology, 3168 square feet. (Design: Jain Malkin Inc.) 



254 Diagnostic Medicine 




TECH SORTING - 



•-SINK UNDER ^ TANKS ON 
HINGED COUNTER CART 



RADIOLOGY (FILM BASED) 



7400 SF 



Figure 5-5. Space plan for film-based radiology 
suite, 7400 square feet (Design: Jain Malkin Inc.) 



Diagnostic Imaging 255 




Figure 5-6. Radiologist's diagnostic console. (Photo courtesy: DR Systems, Inc., San Diego, CA.] 



Figure 5-7. GE RadWorks 5.0 PACS image 
distribution system. [Photo courtesy: GE 
Medical Systems, Waukesha, Wl.) 



The facilities in Figures 5-8 and 5-9 also show separa- 
tion of patient and staff flow into each procedure room. 
Both of these facilities are totally digital with no darkroom, 
yet the imaging rooms look quite the same as film-based 
rooms with the exception that the control area is a bit larg- 
er and has a countertop. Figure 5-1 shows a central con- 
trol area that serves four general radiography rooms that 
are not direct digital, but use computed radiography (CR), 
which can be viewed through the PACS. 

Staff Flow 

Staff flow must be planned carefully with the X-ray tech- 
nologists who will work in the clinic. Certain imaging 
modalities such as CT, ultrasound, and nuclear medicine 
may have dedicated technologists. There must be ample 
space for all of these technologists to pass one another in 




256 Diagnostic Medicine 



corridors and process their films without bumping into one 
another, as well as a place to sort and view films (in a film- 
based setup). In a digital setting, the same amount of tech 
work space is needed but it may be configured differently. 

Figure 5-1 1 presents a schematic layout for a radiolo- 
gy suite, indicating separate entries to procedure rooms 
for patients and for techs as well as other functional adja- 
cencies. Figure 5-4 shows a small radiology suite with the 
tech work area behind the darkroom. In this plan, patients 
have no access to the tech area, nor do they have oppor- 
tunity to overhear conversations or see other patients' 
images on view boxes or monitors. 

It is desirable to provide a separate staff bathroom 
because patient bathrooms are often in use, and those 
serving the R/F rooms can get messy. Front office staff 
function as they would in any medical practice, although 
the high volume of patients in a radiology suite may neces- 
sitate a larger waiting room and a wider reception transac- 
tion area (Figures 5-12 and Color Plate 22, Figure 5-13). 

Information Flow 

Information flow is dictated by PACS and network system 
design rather than by space planning. A typical PACS 
configuration is illustrated in Figure 5-14. Individual sys- 
tem configurations will be as varied and unique as the 
enterprises they serve. However, Figure 5-14 explains the 
general flow of data. Physical space allocation doesn't dif- 
fer demonstrably from film-based settings or any contem- 
porary office for that matter because the same general 
components can be found such as multiple numbers of 
monitors, servers, and printers. These happen to be spe- 
cialized for diagnostic imaging but in terms of space allo- 
cation, there isn't much difference. The one area in which 
there is a huge saving of space, when comparing film- 
based and digital settings, occurs in storage. With film, 
huge storage capacity is required (as well as structural 
accommodation to support the weight), whereas an enor- 
mous amount of imaging data can be stored digitally in 
components placed in a small room. 

What differentiates one PACS from another is (as with 
any software) the way it's configured to meet specific 
needs in the most user-friendly manner. The flow chart in 




KAISER UNION CITY MOB 

5000 SF 



Figure 5-8. Outpatient 
diagnostic imaging cen- 
ter, 5000 square feet 
(fully digital). Kaiser 
Permanente Health Plan 
Union City MOB. 
(Architecture and interior 
design: SmithGroup, San 
Francisco, CA.) 



Diagnostic Imaging 257 




r^gon 



Figure 5-9. Outpatient imaging center, 7500 square feet (fully digital). Santa 
UCLA Outpatient Imaging Center 7,500 sf Monica/UCLA. (Architecture and interior design: SmithGroup, San Francisco, CA.) 



258 Diagnostic Medicine 



Figure 5-14 was provided by DR Systems to visually 
describe how its multicomponent modular system 
employing proprietary software (as well as hardware 
components) functions to input, display, archive, transmit, 
and print radiographic images and, at the same time, 
manage patient demographic, scheduling, and reporting 
information. It was designed by radiologists. One compo- 
nent is an Intranet server that frequently polls the main 
central image server to update, compress, and reformat 
files and data so that images can be viewed using a stan- 
dard Internet browser. The Intranet access serves refer- 
ring physicians or radiologists who are able to log on from 
remote sites using a password, which then enables them 
to pull images and view them on a PC. The recipient can 
be located in a remote office and access the system via 
a dial-up service or a local-area network (LAN) or wide- 
area network (WAN). The reference to HL-7 refers to the 
standard interface between HIS (hospital information sys- 
tems) and RIS (radiology information systems). Each 
PACS offers different features with the overall goal of 
enterprise-wide connectivity, eliminating the need to 
redundantly enter data. 

Function 

A functional layout is one that separates patient and staff 
flow, as discussed above, and one that has a logical 
placement of rooms based on patient volume and other 
considerations. For example, the patient dressing area 
should be near the procedure rooms. 

The general radiography room for chest films is best 
located near the front of the suite as these are short exam- 
inations, but can be high volume, necessitating a number 
of dressing rooms nearby. The radiologist's private office 
and reading room, on the other hand, should be located in 
the most remote and quietest part of the suite. 

A functional construction issue relates to the size of 
studs around procedure rooms. Six-inch studs are a 
wise choice to accommodate all the conduit for cabling. 
Since imaging is such a technologically driven space, 6- 
inch studs should be considered for other areas, as 
appropriate. 




Figure 5-10. Control area for general radiography rooms. Santa Clara Valley Medical Center. {Architecture: 
Anshen+Allen, San Francisco, CA; Photographer: Robert Canfield Photography.) 



Flexibility 

Flexibility is desirable in any healthcare facility because 
technology is advancing so quickly that it is hard to fore- 
cast space needs 5 or 10 years in the future. As diag- 
nostic imaging rooms are very costly to construct, plan- 
ning for future expansion is critical, knowing that optimal 
patient and staff flow can be maintained and the addi- 
tion of new procedure rooms will not create awkward 
adjacencies. Flexibility can also be achieved by making 
rooms larger than the manufacturer's minimum require- 
ments. 



Diagnostic Imaging 259 



£API0U?£Y 



Components of a Diagnostic Imaging Suite 




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PATIENT gl^ 
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These are the basic components of a radiology suite, and 
each will be discussed in detail: 

1 . Waiting room 

2. Business office 

3. Patient dressing 

4. Tech work area 

5. Reading and consultation (may be film or digital 
image) 

6. Film filing (if digital, data storage room for server and 
archives) 

7. Film or digital image processing (darkroom, daylight, 
orPACS) 

The various types of radiography and imaging rooms will 
be described separately. 



R A0OLOGY RECEPtion 



Figure 5-12. Radiology registration desk has "friendly" 
appearance. (Design: Jain Malkin Inc.) 




260 Diagnostic Medicine 



DICOM AND HL-7 COMPLIANT 




Guardian CD-ROM (600) Disk Referring Physician High Resolution 

Jukebox Access using the Glossy Printer 

Expandable to tit Individual Internet 
Archive Requirements 



High Resolution Plain 
Paper Printer 



Radiologist on-call 



Laser Camera Interface 



Figure 5-14. Diagram of PACS system design. (Illustration courtesy: DR Systems, Inc., San Diego, CA.) 



Diagnostic Imaging 261 





Figure 5-1 5a. Radiology waiting area uses low walls to create privacy groupings. 
{Design: Rita St. Clair Associates, Baltimore, MD; Photographer: Gordon Beall 
Photography.) 



Figure 5-1 5b. Diagnostic imaging waiting room divides seating into privacy groupings. {Architecture and 
interior design: Loebl Schlossman & Hackl, Chicago, IL; Photographer: Bruce Vanlnwegen.) 



Waiting Room 

Allow 2.5 waiting room seats per procedure room and 
provide a suitable space out of the traffic lane for a patient 
in a wheelchair. (In a digital setting, there is more 
throughput or higher volume, necessitating more seats 
per procedure room.) At times, a patient may be brought 
in on a stretcher or gurney. This should be taken into 
account when laying out the space, but it is desirable for 
the stretcher to be brought through a private staff 
entrance (rather than the waiting room), through the cor- 
ridor and into a procedure room, without causing damage 
to walls or needlessly jostling the patient. 



262 Diagnostic Medicine 



In a large radiology facility, the number of chairs in the 
waiting room can make it look like a bus station. It is 
preferable to divide the seating into privacy groupings, 
providing several styles of seating to accommodate indi- 
vidual comfort (Figure 5-1 5a). Figure 5-1 5b portrays an 
excellent solution as the wood grid partition provides pri- 
vacy without sacrificing the ability of staff to monitor the 
room. Ceiling design and lighting offer variation and inter- 
est. The use of light and dark woods gives this area a 
warm, inviting appearance. 

Business Office 

The business office is generally not large in a radiology 
suite, because this is a referral practice, and the patient's 
medical record remains with the referring physician. The 
radiologist stores only the X-ray films and a brief report 
on each patient. Billing and bookkeeping may be done 
within the suite or at another location. In a fully digital set- 
ting, an integrated data management system can handle 
billing and insurance claims, inventory of supplies, 
reports to referral physicians, as well as manage all the 
radiographic digital images. Radiographic images for the 
recent week would, of course, be on line, accessible from 
the server for the radiologist in writing reports. 

It is common for radiology groups to sign contracts with 
hospitals to staff their radiology departments. It is not 
unusual for one large radiology group to staff three hos- 
pitals in a city, in addition to staffing and owning a num- 
ber of outpatient radiology clinics in various medical build- 
ings throughout the city. If such is the case, bookkeeping 
and billing might be done off site at a centralized location 
for all of the clinics. Likewise, archiving of near-line and 
off-line images may also be at a central location. 

Patient Dressing 

Allow two dressing rooms for each procedure room. 
Rooms may be as small as 3 feet widex4 feet deep, but 
they should have a chair or built-in bench, mirror, shelf for 
disposable gowns, and one or two hooks for clothing 
(Figure 5-16). A proportional number of dressing rooms 
must be handicapped accessible. Sometimes dressing 
rooms have an emergency buzzer for summoning staff. In 




Figure 5-16. Radiology dressing rooms. {Design: Rita St. Clair 
Associates, Baltimore, MD; Photographer: Gordon Beall Photography.) 



a clinic with a sufficient number of dressing rooms, 
patients may leave their personal effects in the dressing 
rooms, which should have a lockable compartment for 
handbags, briefcases, or jewelry if the room cannot be 
locked. 

In other clinics, patients are asked to store their cloth- 
ing in lockers outside the dressing room, so that others 
may use the room as in Figure 5-17, which also serves as 
a sub-waiting area. The dressing area should be carpet- 



Diagnostic Imaging 263 




Figure 5-17. Radiology sub-waiting and locker area. University of California San Francisco. {Architecture and interior 
design: Anshen+Allen, San Francisco, CA; Photographer: Robert Canfield Photography.) 



ed, since patients may be walking barefoot. Sometimes 
one dressing cubicle is made double-width so that the 
built-in bench may serve as a recovery cot in case a 
patient feels ill. This oversized dressing room also accom- 
modates a patient in a wheelchair. 

Tech Work Area 

A discussion of the technologists' work space must begin 
with a clarification of terms. Although often used inter- 
changeably, there is a difference between technician and 



technologist initiated by the change in name of the 
American Registry of X-ray Technicians to the American 
Registry of Radiologic Technologists. The term "technolo- 
gist" recognizes the evolution of education and skills — the 
X-ray technician has become a radiologic technologist. 

Many diagnostic procedures are performed entirely by 
the X-ray technologist, without the radiologist being pres- 
ent. The tech greets the patient, gives instructions for the 
examination, sets up the equipment, positions the patient, 
makes the exposure, processes the film (or manipulates 
the digital image), and places the finished films in the 
radiologist's reading room or, in the case of digital 
images, routes them to the network. 

The darkroom (if any) should be located close to the 
procedure rooms to save steps for the tech who walks 
back and forth, picking up unexposed film cassettes from 
pass boxes located in the darkroom wall, and, later, 
returns to the pass box the exposed film to be fed into the 
processor from the darkroom. This, of course, applies to 
a film-based setting. 

A suite with three or more procedure rooms will gener- 
ally have a dedicated darkroom technician who continually 
replenishes the pass boxes with film cassettes and feeds 
the exposed film into the processor. The processed film 
drops out of the processor on the daylight side, where the 
tech picks it up, checks it on the view box, sorts a series of 
films, puts it in X-ray film jackets, and later delivers it to the 
film viewing room for the radiologist to interpret. Note that 
techs need access to film filing, as they often have to pull 
older films for the radiologist to compare with new ones. In 
the digital setting, a passive viewing station (Figure 5-7) 
can be used by the tech to locate prior diagnostic studies 
to route them, along with the new images, for comparison 
and interpretation by the radiologist. 

Before the film is fed into the processor, it must have 
patient identification placed on it. The patient identifica- 
tion camera could be on the countertop outside the dark- 
room or may be inside the darkroom. In a digital setting, 
patient identification is bar-coded and executed by the 
PACS software. 

In a film-based setting, each tech requires a stand-up- 
height countertop work surface for sorting and viewing 



264 Diagnostic Medicine 




Figure 5-18. Tech work area, sorting and viewing counter. Note sink 
under hinged countertop. (Design: Jain Malkin Inc.; Photographer: John 
Christian.) 



Figure 5-19. Tech work area (opposite side). Note pass boxes to dark- 
room and automatic processor (outdated model) and film sorting bins 
under pass boxes. 



films. Mounted over the countertop would be a four- to 
six-panel view box illuminator and, below, a rack with a 
number of vertical dividers for sorting films (Figures 5-18 
and 5-19). In addition, a double-panel view box must be 
provided immediately adjacent to the processor on the 
daylight side for checking films as they exit the processor. 
(See the Appendix for mounting heights of view box 
illuminators.) The tech work area in Figure 5-19 depicts 
cassette pass boxes in the wall contiguous with the dark- 
room. When the cassettes have been loaded with unex- 



posed film, they are removed from the "tech side" if the 
darkroom is not contiguous with the radiography room, as 
is the case here. In a fully digital environment, the tech 
work area would be a viewing station (Figure 5-7), at 
either sit-down or stand-up height, with one or more print- 
ers. Hard copies of diagnostic studies may be printed on 
paper or film and sent to the referring physician along 
with a report. 

The control area, discussed in detail below, is also the 
tech's work area. 



Diagnostic Imaging 265 



>< - 




Figure 5-20. Prestige II digital radiography/fluoroscopy unit. {Photo courtesy: GE Medical Systems, Waukesha, Wl.) 

Control Area. Note that, when laying out radiographic flu- 
oroscopy rooms, the tables tilt so that the right side goes 
down, and the left up, when one is standing on the work- 
ing side (Figure 5-20), although some newer tables tilt in 
both directions. The control area, therefore, should be on 
the right end so that the technologist can see the patient 
at all times. General radiography tables do not tilt, making 
this issue less critical, but it is still optimal for the technol- 
ogist to have the patient in view. It is surprising how often 
this planning error occurs. 



Figure 5-3 shows a frequently used layout with a con- 
trol area that runs between two radiography rooms. The 
problem with this, although it is convenient with respect to 
the darkroom and pass boxes, is that a right-handed and 
a left-handed room have been created. And this condition 
does not differ in a digital setting. The R/F room on the 
right puts the control area behind the patient's head, 
whereas the R/F room on the left keeps the patient in full 
view of the tech, especially when the table is tilted. In the 
room on the right, when the table is tilted, the patient 
would be totally out of view of the tech. (As a point of 
information, all R/F tables tilt.) Note that in Figures 5-4 
and 5-5 the control area for the R/F room is located so 
that the tech has a good view of the patient when the 
table is tilted. 

The control area may be outside the radiography room 
as in Figure 5-5 (the operator or technologist looks 
through a lead-shielded window at the patient), or it may 
be in the radiography room (Figures 5-4, 5-8, and 5-9), 
provided the control partition and window are lead shield- 
ed (Figure 5-21). Prefabricated, lead-lined control parti- 
tions and lead-shielded windows may be purchased from 
X-ray supply dealers. 

If the control area is outside the room, a method of ver- 
bally communicating instructions to the patient may be 
required. As a safety precaution, the control console is 
wired to a red signal light outside of each radiographic 
room to prevent entry when the machine is in use. 

The facility in Figure 5-3 has been designed as a hybrid 
facility with two film-based R/F rooms and a digital gen- 
eral radiography room and a digital CT room. Were it to 
be converted to a totally digital environment, the control 
area between the two R/F rooms would be the same 
except a countertop would span the two wing walls and 
the control equipment would sit on the countertop. What 
is currently the darkroom would become a tech work 
alcove with a passive viewing station and printer. 

Reading and Consultation 

Reading Room — Film. The film reading room is where 
the radiologist interprets the films. It is approximately 
10X12 or 10x14 feet in size, with a countertop along one 



266 Diagnostic Medicine 



or two walls at sit-down height. Above the countertop are 
two tiers of view box illuminators lining the room, wall to 
wall. The countertop needs to be completely clear under- 
neath so that the radiologist can move freely from side to 
side. A cantilevered countertop can be accomplished with 
steel reinforcement inside the wall, extending underneath 
the countertop. 

Ideal room lighting would be a perimeter valance (with 
dimmer control) running along two or three walls of the 
room. This would provide glare-free indirect illumination. 
This room should be located in the staff work area or at 
the rear of the suite where it is quiet. It should not be in 
the front of the suite or in the hectic patient circulation 
area. 

Occasionally, radiologists view films on an alternator 
(Figure 5-22), which rotates a series of films that have 
been preloaded, as opposed to manually mounting a 
series of films on view boxes. Alternators are quite large 
and, like film illuminators (which will also be in the room), 
need to be positioned to avoid glare. Mammography films 
are often reviewed on an alternator, which may be sup- 
plemented by an additional monitor and software that 
acts like a spell checker to identify microcalcifications and 
masses. As an example, R2 Technology, Inc., has loaded 
detection algorithms and a large database into its 
ImageChecker® software for screening mammography. 
The processing unit that does the scanning is often 
placed in the tech work area and the display unit 
(CheckMate™) located in the reading room. 

Reading Room — Digital. A reading room in a totally dig- 
ital setting can be smaller than one used for reading films, 
but there are numerous environmental issues that must 
be addressed. The following information is based on an 
article by Bill Rostenberg, FAIA.* Reading workstations 
for radiologists must be designed with great care, working 
closely with the individuals who will work there. Issues of 
privacy if more than one radiologist will use the room 
simultaneously loom large because distraction must be 



*Bill Rostenberg, 1998. "Success by Design: Maximizing Your Digital Environment." 
Advance for Administrators in Radiology and Radiation Oncology 1 4. 




Figure 5-21. GE Revolution XQ/i digital tech console. (Photo courtesy: GE Medical 
Systems, Waukesha, Wl.) 



avoided; as voice recognition systems become more 
common, extraneous noise can be a problem and, if one 
individual is looking at films on a view box (which pro- 
duces very bright light compared with a computer moni- 
tor), this can create glare on the other individual's moni- 
tor. PACS workstations may be configured differently, 
reflecting individual preferences, which includes the num- 



Diagnostic Imaging 267 




Figure 5-22. Film alternator viewing unit. {Design: Jain Malkin Inc.; 
Photographer: Glenn Cormier.) 



ber of monitors, the depth of the countertop, and the loca- 
tion of the keyboard tray (if any). In addition to reading 
and interpreting radiologic images, the radiologist may 
dictate, talk on the phone, do handwritten paperwork, or 
bar-code entry. 

Lighting. Lighting in a reading room should be indirect, 
able to be dimmed, and divided into several zones so that 



one workstation can be controlled or dimmed independ- 
ently of others. Because conventional film illuminators 
produce an average of 880 footlamberts and a CRT offers 
20 to 180 footlamberts, designing an environment that 
accommodates both is tricky. The level of luminance also 
relates to the amount of reflected glare. 

Ambient lighting for computer workstations should min- 
imize contrast between the monitor and surrounding sur- 
faces in order to avoid eyestrain, yet the room must be 
sufficiently dark — and without glare — for the image on 
the screen to be readable. A relationship of 1 : 1 between 
ambient light and that of the display terminal is recom- 
mended. Task lighting can be used to supplement ambi- 
ent lighting where more light is required for handwriting or 
illuminating a keyboard. If task lighting is to be used, con- 
sider electrical outlet locations so that they are conven- 
ient and electrical cords are not running to distant outlets. 

Anyone who works at a computer terminal knows the 
problems caused by glare from overhead lighting, white 
walls parallel to the screen, windows, and other monitors 
on a parallel wall. In the reading room, glare on a screen 
is far more than an annoyance and a cause of eyestrain: 
It can make it difficult to interpret an image. Flat-screen 
monitors that don't use cathode ray tubes and minimize 
glare are becoming increasingly popular. To minimize 
reflection on the screen, walls should be a medium tone, 
never white. Plastic laminate countertops should be dark 
as should any shelves or other casework in the room that 
might reflect on the screen. 

Task lighting may also be accomplished by narrow- or 
wide-beam halogens mounted on tracks or cables that 
allow for quick and easy repositioning. Room lights may 
alternately be controlled on a panel at the radiologist's 
workstation, so that lights may be turned on or off in var- 
ious zones without leaving one's chair. 

Ergonomics. As in any computer workstation, it is desir- 
able to be able to adjust the height of the work surface to 
accommodate tall or short individuals, and, of course, the 
chair should be a quality ergonomic design that provides 
adjustment of arm height, rake of the back, and seat 
height. Fixed countertops do not afford flexibility; howev- 



268 Diagnostic Medicine 



er, a number of manufacturers offer freestanding work- 
stations with maximum ergonomic adjustment. Refer to 
Chapter 3 for a detailed discussion and illustrations of 
ergonomic issues, some of which may apply to a reading 
room. 

HVAC. Thought should be given to zoning the film read- 
ing room independently as PACS workstations and 
numerous monitors give off considerable heat. The radi- 
ologist should be able to control the temperature from a 
thermostat in the reading room. 

Electrical. The key to any high-functioning digital system 
is an uninterrupted power supply. Disturbances from 
other equipment, inadequate system capacity, and inade- 
quate grounding can cause fluctuations that are devas- 
tating to electronic instruments. Newer electronic instru- 
ments are far more sensitive to power line disturbances 
than their predecessors. Even minimal amounts of elec- 
trical noise can affect the dense digital circuitry of these 
advanced microprocessors. UPS units can be attached to 
each electronic instrument or be built into the infrastruc- 
ture of the facility. 

Summary. For now, reading rooms may need to accom- 
modate conventional film-based "hard copy" reading 
along with "soft copy" reading in a hybrid transition phase 
until fully digital soft-copy reading is commonplace. This is 
expected to change quickly. CT and MRI, because they 
are already inherently digital, will be the first modalities to 
come on line with R/F and general radiography following 
along. A resource, for keeping in touch with these issues, 
is the Society for Computer Applications in Radiology 
(SCAR) in Great Falls, Virginia (www.scarnet.org). 

Referring Physicians' Viewing. This is generally an 
alcove off of the corridor (see Figure 5-8, where it is 
labeled "viewing consultant," and Figure 5-3), to which 
referring physicians may come to review their patients' X- 
rays in a film-based (or digital) setting. A four-panel view 
box is generally sufficient. This would usually be at a sit- 
down height, but could be a stand-up consultation area 




pi£81HlS 



Figure 5-23. Six-over-six view boxes. {Photo courtesy: GE Medical Systems, Waukesha, 1/1//.) 



(Figure 5-23). This room should be positioned in the suite 
so that physicians' discussions will not be overhead by 
patients. If located near the front of the suite, or the staff 
entry, doctors would not have to intrude upon patients in 
the examination area. In a fully digital setting, the physi- 
cians' viewing area may be fairly small (Figure 5-3) and 
would have a passive viewing station as in Figure 5-7. 
Increasingly, referring physicians will be viewing patients' 
radiographic images via the Internet in their own offices. 

Radiologist's Office/Consultation. The radiologist usu- 
ally does not consult with patients, but does consult with 
referring physicians. This may take place in the private 
office or in the referring physicians' viewing area. (Those 



Diagnostic Imaging 269 




Figure 5-24. Kodak DryView™ 
Jain Mai kin Inc.) 



8700 laser imager. (Photo courtesy: 



who do consult with patients would use the private 
office.) In a film-based setting, most radiologists will 
have view box illuminators in their private offices (four- 
over-four or perhaps eight-over-eight panels) mounted 
on the wall behind and to the side of the desk, with a 
sorting shelf underneath. In a digital setting, the film illu- 
minators would be replaced by a PACS workstation as in 
Figure 5-6 or possibly a passive viewing station (Figure 
5-7). This room should be located in the quietest part of 
the suite. Expectations are that telephone consultations 
supported by images sent over the Internet will replace 
face-to-face encounters between radiologists and refer- 
ring physicians. 



Film Filing 

Sufficient storage for X-ray films must be provided in spe- 
cial-sized lateral file cabinets. Films are placed in color- 
coded paper jackets and stored on open shelves for easy 
retrieval. (X-ray film jackets are 14 1 / 2 x17 1 /2 inches in size.) 
Many radiology suites use space-saving movable aisle- 
type filing systems, which may be manually operated or 
motorized. A word of caution: The weight of these file cab- 
inets, loaded, must be carefully calculated in order to 
design the floor to support it. 

Digital Data Storage 

This was explained under the PACS section at the begin- 
ning of this chapter. A facility may or may not have a stor- 
age room to accommodate a large server and jukebox 
tower for archival storage. The facility in Figure 5-8, for 
example, is part of a 250,000-square-foot building that 
has telecommunications equipment rooms disbursed 
throughout it. The facility in Figure 5-9 is also part of a 
larger facility. An independent radiology suite as in Figure 
5-3 (although this one is not fully digital), located in a 
medical office building, does need a room for data stor- 
age equipment. 

Film Processing 

Film processing may be done in a darkroom or by a day- 
light process that does not require a darkroom or by a 
dry view laser imager (can be used with CT and MRI). 
However, daylight processing also requires a small dark- 
room, which does not need plumbing — just literally a 
dark room with a light seal on the door and a countertop 
for loading film into magazines. The dry view laser imag- 
er does not require a darkroom; the machine contains a 
cartridge that holds a quantity of film. For this type of 
processing, one must be able to send a digital image 
directly to the laser imager (Figure 5-24). As film may be 
used in many facilities for a number of years, film-based 
processing systems will be discussed. The large central 
darkroom that necessitates long travel routes has been 
replaced, in large facilities, by a number of processing 
areas distributed in a decentralized fashion throughout 
the suite, adjacent to procedure rooms. An individual 



270 Diagnostic Medicine 



procedure room such as mammography or MRI might 
have a dedicated film processor (daylight for mammog- 
raphy or dry view laser for MRI) that does not require a 
darkroom. 

The advantages of decentralized darkrooms and pro- 
cessing are several. They free the tech from carting cas- 
settes back and forth, which can be tiring. Shorter walk- 
ing distances allow the tech to spend more time with 
patients who, in turn, have a shorter wait because films 
are processed more rapidly. This improves the opera- 
tional efficiency of each procedure room, thereby gener- 
ating more revenue. 

From the planning point of view, there are four different 
possibilities for routing exposed film to the processor. 

1 . Single-film cassette 

2. Transportable film magazine 

3. Daylight system 

4. Integrated (attached) film processor 

The single-film cassette is used in all conventional fluoro- 
scopic and radiographic procedures. Single cassettes are 
loaded and stored in lead-lined cassette pass boxes 
(Figure 5-25). 

The film magazine accommodates a large quantity of 
exposed films that are processed sequentially, together, 
in the processor. 

Daylight systems (used for general radiography and 
mammography) allow the film processor to be located in 
a lighted room. Advocates of this system claim that day- 
light processing saves 20 percent of the total patient 
examination time, allowing the tech to spend more time 
in the room with the patient, rather than running back and 
forth to the darkroom. There may be some savings in uti- 
lization of space as well. A darkroom can be used only 
for opening and processing film, whereas a daylight area 
is all usable space. A daylight processor may be placed 
in the procedure room itself if it is internally shielded from 
radiation but most units are not. This type of processing 
is indicated in Figure 5-5 and described more fully later 
in this section. 



Darkroom. Film-based radiology suites contain one or 
more darkrooms unless they are dedicated to daylight 
film processing. 

The size and design of the darkroom and processing 
area depend on the equipment, the number and arrange- 
ment of radiographic rooms around it, whether there is 
one central darkroom or several decentralized ones, and 
the volume of film to be processed. In any case, there 
would be a "wet" side and a "dry" side. The wet side is 
where the automatic processor and the replenishment 
(developer and fixer) tanks are located. Either inside the 
darkroom or in the tech work area outside, there needs to 
be a large sink (size 18X24x9 inches deep) for washing 
the roller racks of the processor. This sink should have hot 
and cold water as well as a sprayer attachment. Since it 
is not used on a daily basis, it is advisable to put it under 
a hinged countertop (Figures 5-5 and 5-18) to preserve 
more working space. 

The dry side of the darkroom is where the film storage 
bin (which requires an electrical outlet) is located and 
where cassettes are loaded with film. One or more cas- 
sette pass boxes will be built into the wall for the transfer 
of unexposed and exposed film cassettes. Since these 
are very heavy lead-lined boxes, the wall in which they 
are supported will require reinforcement. Pass boxes will 
be located in the wall of the darkroom closest to, or con- 
tiguous with, the radiography rooms (Figures 5-3 and 5- 
4). If the darkroom is not contiguous with the radiography 
rooms (Figure 5-5), pass boxes would be located on a 
darkroom wall accessible to the radiography room corri- 
dor. Daylight processing systems do not require pass 
boxes. 

The automatic processor (Figure 5-26) is typically 
located outside the darkroom, feeding through a light- 
sealed opening in the wall into the darkroom. (The unit is 
outside the darkroom with the feed tray extending into 
the darkroom.) Exposed film is fed from inside the dark- 
room into the tray, and the processed film is delivered on 
the daylight side of the tech work area (Figures 5-3, 5-4, 
and 5-19). 

Processors require only cold water as temperature is 
controlled within the unit. The processor shown in Figure 




Figure 5-25. Cassette pass box. (Photo 
courtesy: GE Medical Systems, Waukesha, 
Wl.) 



Diagnostic Imaging 271 




Figure 5-26. Kodak X-OMAT 3000RA film processor. (Photo courtesy: 
Eastman Kodak Co., Rochester, NY.) 



5-26 is the standard in the industry; therefore, its planning 
requirements will be noted. It needs 36 inches clear on 
three sides for maintenance and repair. The unit requires 
a floor drain or, preferably, a floor sink inside the dark- 
room near the processor and a vent to the outside for 
exhaust. Exhaust comes out of the processor from the 
rear, which can be handled by connecting a flexible duct 
that runs exposed along the inside darkroom wall, or it 
can be run concealed inside the wall at the proper loca- 
tion to connect with the vent hold exhaust pipe at the rear 
of the processor. The unit requires 120/208 volts ac, sin- 
gle- or three-phase, 30-ampere service with a 30-ampere 
breaker. 

Two 50-gallon replenishment tanks of developer and 
fixer can be located under the countertop on the wet side 







Figure 5-27. Safelight. (Photo courtesy: 
Eastman Kodak Co., Rochester, NY.) 




Figure 5-28. Safelight. [Photo courtesy: GE Medical 
Systems, Waukesha, Wl.) 



272 Diagnostic Medicine 



of the darkroom, close to the processor. These tanks may 
also be placed on a rolling cart. Tanks may also be placed 
in a closet adjacent to, but outside the darkroom (Figure 
4-19) and preferably near a service entrance so that ven- 
dors need not enter the tech work core to service the 
tanks. The area under the processor, including the path 
between the processor and the sink used for washing 
rollers, must have hard-surface flooring, preferably sheet 
vinyl. Carpet should not be used in the tech work area 
outside the darkroom. 

A darkroom needs two sources of light. A 100-watt 
incandescent fixture, either recessed or surface mounted 
to the ceiling, will serve for general illumination, but a red 
safelight must be provided for work with exposed film. The 
safelight can be plugged into an outlet at 60 to 72 inches 
off the floor, and it can work by a pull chain or be wired to 
a wall switch (Figures 5-27 and 5-28). If the latter, the 
switch should be located away from the incandescent 
light switch, so that the technologist does not accidental- 
ly hit the wrong switch while working with exposed film. 
The safelight shown in Figure 5-28 can sit on a counter- 
top or be bracketed to the wall. Any recessed light fixtures 
and the exhaust fan must have light sealed housings. 
Similarly, the darkroom door must have a light seal. 
Codes in some cities require a lightproof louver ventila- 
tion panel in the darkroom door. Note that ceilings should 
be drywall to minimize dust. 

Countertop work surfaces in a darkroom may be at a 
height of 34 or 42 inches, depending on personal prefer- 
ence; however, the ADA has a limit of 34 inches high. 
Open shelves may be provided above the countertop for 
storage of various items. There is no need for closed stor- 
age in a darkroom. As for color of walls, some techs pre- 
fer dark walls, while others prefer a light color. 

An option for a darkroom door is that shown in Figure 
5-29, which is also available in a wheelchair-accessible 
version. This revolving door provides lightproof entry into 
the darkroom, allowing one tech to enter while another is 
working with exposed film. If this type of door is not used, 
it is important to have a red warning light over the door 
that is automatically activated (tied into the film bin) 
whenever cassettes are being loaded or unloaded. 




Figure 5-29. View of tech work corridor showing through-the-wall film processor 
("daylight" side) and revolving darkroom door. {Design: Jain Malkin Inc.; 
Photographer: Glenn Cormier.) 



Diagnostic Imaging 273 





Figure 5-30. Silver recovery unit. (Photo courtesy: GE Medical Systems, 
Waukesha, Wl.) 



Figure 5-31. Compact E.O.S. daylight processor system. (Photo cour- 
tesy: Agfa Corporation, Greenville, SC.) 



The darkroom water supply must be filtered, and the 
processor may need a silver recovery unit (Figure 5-30), 
depending on local codes. When disposing of waste 
chemicals or water, regulations of local agencies must be 
followed. If used liquids are allowed to be fed into the 
sewer system, piping must be of polyethylene up to the 
main line (vertical disposal pipe). Additionally, waste lines 
must have vacuum breakers. 

Digital Processing 

This has been discussed previously under PACS and 
Computed Radiography. The tech work area in a fully dig- 
ital environment can be quite large (Figure 5-8), if cen- 
tralized, depending on the volume of films and the num- 
ber of procedure rooms served. For example, the plate 
reader (for phosphor plates) might be the size of a refrig- 



erator, and there may be other peripheral pieces of 
equipment such as laser printers and a PACS viewing 
station that enable techs to access images. 

Daylight Processing. There are a number of daylight 
processing systems as well as options within each sys- 
tem. As with any selection of equipment, it depends on an 
analysis of needs. The layout of the suite, availability of 
space, number and type of radiology examinations, antic- 
ipated workflow, availability of personnel, and, of course, 
cost must all be factored into the decision. Manufacturers' 
literature must be consulted for suggested equipment lay- 
outs, critical distances between various components, 
weight, and utility requirements. 

The daylight processing system shown in Figure 5-31 
(size 37 inches deepX28 inches wideX55 inches high) 



274 Diagnostic Medicine 



can be placed in a daylight processing area or immedi- 
ately outside a procedure room such as mammography, 
both illustrated in Figure 5-5. The processor depicted is 
intended for general radiography and R/F but, with spe- 
cial developer racks, accommodates mammography 
films. 

Today, it is popular to create a women's center within a 
radiology suite. For marketing purposes, this area is gen- 
erally located near the front of the suite and may even 
have a private entrance (Figures 5-4 and 5-5). This means 
that the tech would have quite a distance to walk to a cen- 
tral darkroom or processing area; therefore, a daylight 
processor may be a solution. In Figure 6-6, six mammog- 
raphy rooms are supported by daylight processing. 

Certain issues need to be considered with daylight pro- 
cessing systems. All machine functions are monitored 
and controlled by microprocessors; therefore, manufac- 
turers' recommendations for relative humidity and ambi- 
ent temperature must be heeded. There are two methods 
of discharging waste, water, and chemicals (fixer and 
developer): central discharge into the sewer system, or 
collection of waste into storage tanks. If local codes allow 
for chemicals to be discharged into the public sewer sys- 
tem waste liquids would be run straight to the drain 
through a hose. Polyethylene piping will be needed for the 
drain as far as the main riser (vertical downpipe). An alter- 
native to this is a waste disposal trolley with containers to 
collect the chemicals. 

There are a number of critical plumbing connections 
required with daylight processors. Manufacturers' techni- 
cal planning manuals should be reviewed. For the unit 
depicted in Figure 5-31 , a floor drain is required close to 
the machine, and a sink must be provided for mainte- 
nance work. This is a large, deep sink such as would be 
found in a darkroom for washing the roller rack of a 
processor. Plumbing connections can be made through 
either the bottom or the back of the machine. These 
include an exhaust connection (with flexible hose) and 
connections for water, intake and discharge of fixer and 
developer. Flexible hoses are used because it may be 
necessary to move the machine for repair work and for 
this reason connections through the floor must be 



placed behind the machine, not under it. The processor 
in Figure 5-31 requires minimum clear access of 20 
inches to the rear, 24 inches to the right side, 40 inches 
to the left side, and 28 inches in front. A countertop is 
needed nearby for items such as a patient identification 
camera. 

Additional accessory items that may be internally inte- 
grated into the processing system (or may be accessory 
attachments) are a water filter, replenisher tanks, a silver 
recovery unit, or a chemical mixer. Most daylight proces- 
sors require a dedicated circuit, good ventilation in the 
processing area, controlled water pressure, and a 3- to 4- 
inch-diameter exhaust connect from the processor, vented 
to the plenum or to the outdoors, as local codes dictate. 

To avoid too high a concentration of chemical fumes, 
the air exchange should be 10 times the room volume per 
hour. Consider noise levels when locating these 
machines. In standby mode expect 36 decibels (dB(A)) 
and in film processing mode 51 decibels. Also, the 
machine must not be exposed to direct sunlight. It should 
be noted that some daylight processors can also be locat- 
ed contiguous to a darkroom with a film feed tray through 
the darkroom wall. 



General Radiography Rooms and 
Radiography and Fluoroscopy Rooms 

Not all radiography rooms are equipped for fluoroscopy. A 
diagnostic imaging facility may have two general radiogra- 
phy rooms plus one radiography and fluoroscopy (R/F) 
combination room or perhaps one general radiography 
room and two R/F rooms. The R/F rooms should be a min- 
imum of 14X16 feet in size and may even be 16x18 feet. 
The size of the radiography room will vary in accor- 
dance with the size of the X-ray unit and the ancillary 
equipment. As the room is equipped for taking radi- 
ographs of all parts of the body in standing, sitting, or 
angled positions, the room will have freestanding, wall- 
mounted, and ceiling-suspended equipment. Because 
there are a certain number of variables from one manu- 
facturer to another, the space planner must obtain sug- 



Diagnostic Imaging 275 




Figure 5-32. General radiography room. University of California San Francisco. {Architecture and interior design: 
Anshen+Allen, San Francisco, CA; Photographer: Robert Canfield Photography.) 



gested room layouts that note critical distances between 
various components, along with specifications of required 
utility connections from each manufacturer. Technical 
planning guides should be requested. 

To begin with, electrical cables connect the control unit 
(generator) to the X-ray tube stand and the transformer. 
The most unobtrusive way of handling this is to trench the 
floor and bury them under a coverplate. Conduit or 
cabling can also be run, exposed, at the base of the wall. 
(The transformer is generally located in one corner of the 
radiography room.) 

An R/F room must have a toilet attached to it. The toi- 
let often has one door to the R/F room and another to the 
corridor as shown in Figures 5-3 and 5-4. The patient 
needs to immediately discharge the barium enema after 
the lower Gl (gastrointestinal) procedure. 

The patient exits the bathroom via the corridor door, 
adjacent to the dressing area. If he or she needs to use 
the bathroom again, the patient may enter from the corri- 
dor side, as the next patient would not be using it imme- 
diately. (A certain amount of cleanup time and prep is 
required before examining the next patient.) 

In older facilities, one may find a barium prep area, 
which is a countertop with sink and plaster trap for prepa- 
ration of barium or contrast media and an under-counter 
refrigerator. However, barium now comes prepackaged 
and requires no preparation. 

The fluoroscopy room is the workroom for the radiolo- 
gist. He or she will watch the TV monitor as the patient is 
turned in different positions, and the contrast medium 
moves through the organs. 

The size of the fluoroscopy room is largely determined 
by the amount of ceiling equipment. The ceiling tube mount 
moves on ceiling-mounted tracks, supported by a 
Unistrut® system above the finished ceiling as in Figure 
5-32, although, technically, this is not a fluoro room. When 
a room has a table that tilts (Figures 5-20 and 5-33) and a 
ceiling-mounted tube stand, a 10-foot ceiling height may 
be required. Of course, the weight of the equipment must 
also be considered, which, for fluoro, is about 3000 pounds 
for the table. 



276 Diagnostic Medicine 




Figure 5-33. Clinix™-RF Plus digital radiography/fluoroscopy unit. [Photo 
courtesy: Marconi Medical Systems, Cleveland, OH.) 



Radiography Room Without Fluoroscopy 

A radiography room without fluoroscopy may be as small 
as 12x16 feet, although 12x16 feet would be recom- 
mended only for a compact table that might be used by 
an orthopedist. Always err on the side of a larger, rather 
than a smaller, room. In these compact units, the X-ray 
tube column may be mounted directly to the table, negat- 
ing the additional space required for ceiling mounting. If a 
radiography room is used by a technologist only (as is 
often the case), the room may be smaller than if it is used 
by the radiologist, who may be doing special procedures 
requiring more than one person to be in the room and 
perhaps the use of additional portable equipment. 

Chest films would typically be done in a general radi- 
ography room, although Figure 5-34 shows digital equip- 
ment specifically for chest films. In a general radiography 




Figure 5-34. Digital chest room. University of California San Francisco. {Architecture and interior 
design: Anshen+Allen, San Francisco, CA; Photographer: Robert Canfield Photography.) 



Diagnostic Imaging 277 




Figure 5-35. Chest bucky. {Photo courtesy: Jain Malkin Inc.) 

room, a wall-mounted film holder, called a bucky, would 
be located generally at the "head" end of the X-ray table 
(Figure 5-35), but it may be placed to the side of the table 
(Figure 5-32). Another common procedure, an IVP (intra- 
venous pyelogram), used to study the kidneys, uterus, 
and bladder, is performed in a general radiographic room 
that has tomographic capabilities but these are more 
commonly done with CT. For these studies, a bathroom 
must be nearby, but need not be attached to the room. 

Radiography rooms without fluoroscopy need not have 
sinks, but do require a cabinet and shelves for storage of 



patient positioning devices such as sandbags and foam 
wedges and for disposable items needed for procedures. 

The door to a radiography room must be large enough 
to move equipment in and out. It should be noted that a 
lead-lined door is very heavy and will require a heavy- 
duty closer. Figure 5-3 shows a 42-inch-wide door on the 
R/F rooms, but movement of equipment can also be 
accommodated by a 3-foot-wide door placed in a 4-foot- 
wide frame with a 1-foot dead panel (lead lined) that can 
be removed as needed. 

The four general radiography rooms and the control 
area depicted in Figures 5-10 and 5-36 are not direct dig- 
ital; they use CR, explained previously, which can viewed 
on a PACS. The unit in Figure 5-37 converts traditional X- 
ray films to digital (in lieu of scanning films with a digitiz- 
er) in order to view them on a PACS. This may be located 
in the tech control area and can be shared between two 
general radiography rooms. 

Lead Shielding. Once a radiology suite is designed, a 
radiation physicist must be consulted to prepare a study 
of lead-shielding requirements. In order to do this, the 
physicist will need to know full specifications on the 
equipment for each room, the anticipated volume of films, 
the location of a particular X-ray room with respect to 
adjacent rooms in the suite, and the location of the suite 
itself within the medical office building. 

For example, if a radiology room is on the third floor of 
a building and has two exterior walls, the lead-shielding 
requirements would be considerably different than if the 
room were contiguous with an office where someone sits 
at a desk all day. If the suite is located on the ground floor 
of a building and the radiography room is on an exterior 
wall, with passersby walking to a parking lot, the physicist 
evaluates the volume of foot traffic and the amount of 
exposure in order to "protect the genes of future popula- 
tions." Of course, placement of equipment in the room will 
determine the direction of radiation scatter. 

The lead-lined control partition in Figure 5-36 is viewed 
from the opposite side in Figure 5-10. The leading edge 
must have at least 1 8 inches of wall to the side of the win- 
dow to protect the tech. 



278 Diagnostic Medicine 





Figure 5-36. General radiography room. University of California San Francisco. {Architecture and interior design: Anshen+Allen, 
San Francisco, CA; Photographer: Robert Canfield Photography.) 



Figure 5-37. SmartCR™ computed radiography plate read- 
er with flat-panel touch screen and information processing 
unit. (Photo courtesy: Fujifilm Medical Systems USA, Inc., 
Stamford, CT.) 



Odor Control. To prevent the spread of odors from the 
darkroom, the ventilation system should be designed so 
that negative air pressure, relative to adjoining corridors, 
is maintained. This can be accomplished by exhausting 
more air from this room than is supplied to it. This is only 
an issue if the fixer and developer replenisher tanks are 
located in the darkroom. As always, local codes must be 
followed. Similarly, bathrooms that serve R/F rooms (in 
consideration of the lower-GI examinations) deserve con- 



sideration with regard to exhaust of odors and recircula- 
tion of air. 

Emergency Precautions. When laying out a radiology 
suite, thought must be given to the possible evacuation of 
a patient on a stretcher. Since most radiology suites are 
located on the ground floor, this may be accomplished by 
a secondary exit that leads directly to the parking lot, 
enabling an ambulance to pick up a patient without the 



Diagnostic Imaging 279 



patient having to be carried through the waiting room or 
the building lobby. Resuscitation equipment on a crash 
cart should be readily available to the procedure rooms. 
Radiologists sometimes request emergency call buzzers 
for procedure rooms, patient dressing rooms, and toilet 
rooms. The annunciator panel would be located at the 
reception desk. 

Whenever working with chemicals or reagents, OSHA 
recommends an eyewash device, which can be a divert- 
er attached to a faucet, as in Figure 3-50, or a dedicated 
unit wall mounted or placed in a countertop. The issue 
with an eyewash diverter is that, in a panic, one may turn 
on hot water to wash the eye, whereas a dedicated eye- 
wash unit prevents this. Bear in mind that an eyewash unit 
should be located within a 10-second walk of where the 
accident might occur. Although historically it has not been 
common to locate an eyewash device adjacent to dark- 
rooms or daylight processing units, it may be prudent to 
do so. 

Lighting. There should be two types of lighting in a gen- 
eral radiography or R/F room: overhead fluorescents and 
indirect perimeter lighting, switched separately (Figure 
5-32). Perimeter lighting should be able to be dimmed, as 
fluoroscopy procedures are done in a dark or dimly lit 
room. Note the upgrade to the acoustic ceiling tile in 
Figure 5-32, which adds considerably to the ambience of 
the room, as opposed to seeing exposed ceiling grid and 
the ubiquitous 2-x4-foot acoustical tiles. 



ULTRASOUND 

Since ultrasound does not use radiation, there is no need 
for lead shielding. The room should not be smaller than 
10X12 feet in size. The patient lies on an examination 
table and the technologist typically works to the right side 
of the patient. The equipment is portable (Figures 3-60, 4- 
10, and 4-30), approximately 27 inches widex34 inches 
deepx54 inches high, and consists of a microprocessor, 
videotape recorder, and monitor. Images may be sent to 
a PACS or a laser camera or a video recorder. Enhanced 



ultrasound units provide instantaneous 3-D images of 
anatomical structures including the liver, kidneys, thyroid, 
breast, and fetuses. Ultrasound equipment has no special 
electrical requirements, except for a dedicated circuit. 
However, the room is darkened for the procedure, and an 
ideal type of lighting would be indirect perimeter lighting 
that can be dimmed. 

An ultrasound room must have a toilet immediately 
adjacent to accommodate voiding studies of the bladder. 
A cabinet with sink should be provided in the ultrasound 
room. 



NUCLEAR MEDICINE 

Historically, nuclear imaging equipment was found pri- 
marily in hospitals, rather than in the outpatient setting, 
because of its availability to both inpatients and outpa- 
tients and due to environmental issues of safely han- 
dling and disposing of radioactive materials. Statistics 
indicate that 75 percent of nuclear medicine imaging is 
hospital based; however, it is increasingly appearing in 
outpatient settings. Nuclear imaging also includes PET 
(positron emission tomography) scanners that image 
metabolic and biological functions of the body. An 
impressive new hybrid CT/PET scanner that combines 
the best of both modalities in one unit reveals exquisite 
images of internal anatomy (CT) and images of meta- 
bolic processes (PET). 

Although there are numerous variables in equipment, 
these are the basic components: 

1 . Operator's console/workstation 

2. Detector gantry (single, dual, or triple head) 

3. Collimator 

4. Patient bed (may be part of detector stand) 

A nuclear imaging room does not require lead shield- 
ing, as the gamma camera emits no radiation; it picks 
up the small amount of radioactivity released by the 
organ being imaged. The patient ingests or is intra- 



280 Diagnostic Medicine 



venously injected with a small amount of a radiophar- 
maceutical that travels through the bloodstream to the 
specific organ being studied. The patient prep room 
should be close to the hot lab where the radioactive 
material is prepared so that the tech never has to walk 
through patient circulation corridors carrying radioactive 
material. Having a nuclear scan can be an all-day 
process for a patient as explained below. In the interim, 
while they are radioactive, they should not mix with 
other patients in the waiting room as there is a risk, for 
example, of birth defects should this patient sit next to 
a pregnant woman in the first trimester who is waiting 
for an ultrasound. Sometimes patients leave the facility 
for a couple of hours and then return. A sub-waiting 
area near the nuclear imaging procedure rooms is prac- 
tical, as is a dedicated toilet since human waste dis- 
charged from patients who have ingested radioactive 
materials could splash on the floor or toilet seat. 
Because the type (and amount) of radioisotopes used in 
diagnostic studies (as opposed to treatment) is minimal 
and decays quickly, the toilet waste can generally be 
discharged into the sewer system without being divert- 
ed to a holding tank; however, local codes should be 
consulted. The radioactive material dissipates quickly in 
the patient after the examination has been completed. 
There are many types of nuclear medicine scans, 
including bone, liver, thyroid, lung, and gallbladder scans, 
to name a few. The time between administering the 
radioactive compound and taking the scan may vary, 
depending on the compound used and how long it takes 
to accumulate in the part of the body being studied. Some 
scans are performed a few hours after the injection, while 
others may be performed immediately. The scan itself 
may take anywhere from 30 minutes to two hours, again 
depending on the part of the body being studied. Gamma 
cameras may have single, dual, or triple detectors. A dual 
or triple head cuts the scan time because scanning is 
done from several locations at the same time. Collecting 
the data is vastly increased. Figure 5-38 shows the man- 
ufacturer's suggested layout for equipment shown in 
Figures 5-39 and 5-40. Because layout options for 
nuclear imaging equipment can vary considerably in 



Room Layout Examples 



EC AM with left side 
patient access shown in 
large room. 



■V- 




HO cm (IS ft Sin) 



E.CAM with right side 
patient access shown in 
small room. 



Figure 5-38. Suggested room 
layouts for Siemens e.cam™ 
nuclear medicine gamma 
camera. See Figures 5-39 
and 5-40 for equipment 
depicted in this site plan. 
{Illustration courtesy: 
Siemens Medical Systems, 
Inc., Hoffman Estates, IL.) 



V 



73 cm 
(2 tl 4-3/4 In) 



Home: 101 cm (39-3/4 In) 
Min : 78 cm I38M In) 
Mai: 106 cm (41-3J4 In) 



32 

(12.S In) 



Home: 76 cm (30 In) 
Mln: 71 cm (29 In) 
Max: 99 cm (39 In) 




Nuclear Medicine 281 




Figure 5-39. Siemens e.cam™ dual-detector-head nuclear medicine gamma camera. (Photo courtesy: Siemens Medical 
Systems, Inc., Hoffman Estates, IL.) 



Figure 5-40. Siemens e.cam™ dual-detector-head nuclear medicine 
gamma camera, posterior seated view. (Photo courtesy: Siemens 
Medical Systems, Inc., Hoffman Estates, IL.) 



shape and size, manufacturers should be contacted for 
suggested room layouts. As with any radiographic equip- 
ment, weights that exceed 3000 pounds require careful 
structural analysis as does the path of travel into the room 
and through doors. An example of a nuclear imaging 
workstation is depicted in Figure 5-41. The operator's 
console is in the procedure room and does not require 
lead shielding or enclosure. 

The space planner may encounter the terminology 
SPECT in regard to nuclear imaging procedures. It 



refers to single-photon emission computed tomography 
capability. 



Nuclear Stress Test 

This is used in conjunction with a dynamic ECG. The 
room may have a nuclear cardiology scanner (or a "gen- 
eral purpose" gamma camera), a workstation for the tech, 
and possibly a treadmill, although cardiac stress can also 



282 Diagnostic Medicine 



be imposed pharmacologically. This equipment may be 
accommodated in a dedicated room or it may be per- 
formed in a larger multipurpose nuclear imaging room. 



Positron Emission Tomography 

PET is a nuclear technology that offers intimate glimpses 
of molecular functioning (Figure 5-40). The volume of PET 
scanners in the total marketplace nationally is low due to 
the significant cost and licensing issues regarding techni- 
cal staff who administer the scans. The PET market was 
given a boost in mid-1999 when HCFA decided to allow 





Figure 5-41. Siemens e.cam™ nuclear medicine operator's 
console. (Photo courtesy: Siemens Medical Systems, Inc., 
Hoffman Estates, IL.) 



Figure 5-42. Siemens biograph combination CT/PET scanner. (Photo courtesy: Siemens Medical Systems, 
Inc., Hoffman Estates, IL.) 

reimbursement of PET scans for five types of cancer, 
including cancer staging (a method of evaluating tumor 
growth), based on a number of clinical studies demon- 
strating that PET was considerably more accurate than 
conventional CT imaging for patients with certain types of 
cancers. HCFA is expected to expand its coverage of PET, 
which will most likely energize the market, but the combi- 
nation PET/CT (Figure 5-42) is expected to constitute the 
state of the art for cancer diagnosis and management. In 
some regions, entrepreneurial radiologists have joined 
together in a business venture to purchase a PET scanner 
and contract with hospitals. Sometimes these are dedicat- 
ed PET centers with no other imaging modalities. 



Nuclear Medicine 283 




Figure 5-43. Clear-Pb nuclear medicine 
mobile barrier. {Photo courtesy: Nuclear 
Associates, Carle Place, NY.) 





Figure 5-44. Lead-lined refrigerator, hot lab. {Photo cour- 
tesy: Nuclear Associates, Carle Place, NY.) 



Figure 5-45. Interlocking lead bricks. 
(Photo courtesy: Nuclear Associates, 
Carle Place, NY.) 



It should be noted that PET scan rooms do require lead 
shielding and that PET involves higher levels of radioac- 
tivity than with the standard nuclear gamma camera. The 
techs are in a separate room, similar to the layout for an 
operator's console in CT or MRI. 



Tech Shielding 

When tech shielding is required, the nuclear medicine 
mobile barrier in Figure 5-43, featuring lead-impregnated 
acrylic, may be used. The oversized window permits unob- 
structed viewing of the patient. This barrier (which comes 
in many sizes) may be positioned close to the patient table, 
and it shields the tech from patient-emitted radiation. 



Hot Lab 

This is a room, perhaps no larger than 6x8 feet, where 
radiopharmaceuticals are prepared. This is best located 
in a part of the suite where there is not a lot of traffic. It 
should be noted that unit-dose, freeze-dried "kits" specif- 
ic to each study (e.g., lung kits, bone kits, etc.) have 
greatly reduced the amount of prep required and the 
amount and type of storage needed. With unit dose, a 
refrigerator and the various bins depicted in Figure 5-46 
are not required, but as the use of unit dose is not uni- 
versal, these items are pictured. The room would have 
34-inch-high countertops with a single-compartment sink, 
and may have a lead-lined undercounter refrigerator 
(Figure 5-44), with some open shelves and hinged-door 
storage under the countertop. Note that the countertop 
must be steel reinforced in order to support the interlock- 
ing lead bricks (Figure 5-45) that will be placed on it. 
These may total as much as 1000 pounds. It may be 
more practical to buy a prefabricated workbench 
designed specifically for handling, storing, and disposing 
of radioactive materials (Figures 5-46 and 5-47). The 
modules of these workbenches are lead lined and 
encased in steel. Stainless steel countertops allow for 
easy cleaning and decontamination. 



284 Diagnostic Medicine 





Figure 5-46. Workbench for handling radioactive materials. 
(Photo courtesy: Nuclear Associates, Carle Place, NY.) 



Figure 5-47. Workbench for handling, storing, and disposing of radioactive 
materials (stainless steel countertop). (Photo courtesy: Nuclear Associates, 
Carle Place, NY.) 




Radioisotopes are stored in vial shields (Figure 5-48) 
from which the contents are dispensed. Vial shields of 
radiopharmaceuticals are stored in a small safe made up 
of interlocking lead bricks or in a lead container such as 
that shown in Figures 5-49 and 5-50. These containers 
may be placed on the countertop or on a shelf under it — 
one with enough space to lift the lid and access the con- 
tents of the safe. 

Remember that safes range from 1 25 to 200 pounds in 
weight. Figures 5-51 a and 5-51 b show clear benchtop 
shields that provide a protective lead barrier from radia- 
tion exposure when working with radionuclides. 

Electrical outlets are required over the countertop for 
radioisotope calibrators (Figure 5-52), the wipe test 
counter (Figure 5-53), and other accessory items. There 
is a need for storage of items used to mix agents such as 
vials and syringes, for gloves, and for gripping tools. 




Figure 5-48. Vial shield for 
viewing, handling, and dis- 
pensing radioactive liquids. 
(Photo courtesy: Nuclear 
Associates, Carle Place, NY.) 



Figure 5-49. Square lead container 
for storing radioactive materials. 
(Photo courtesy: Nuclear 
Associates, Carle Place, NY.) 



Figure 5-50. Lead storage container 
(safe) for storing radioactive materials. 
(Photo courtesy: Nuclear Associates, 
Carle Place, NY.) 




Nuclear Medicine 285 





Figure 5-51 a. Protective lead barrier for bench- 
tops, hot lab. {Photo courtesy: Nuclear Associates, 
Carle Place, NY) 



Figure 5-51 b. Protective lead barrier for 
benchtops, hot lab. (Photo courtesy: 
Nuclear Associates, Carle Place, NY.) 





Figure 5-53. Wipe test counter. {Photo courtesy: 
Nuclear Associates, Carle Place, NY.) 



Figure 5-52. Computerized radioisotope calibrator. 
{Photo courtesy: Nuclear Associates, Carle Place, NY.) 



COMPUTED TOMOGRAPHY 

The CT suite consists of a scanner or procedure room 
and a room with an operator's console. Manufacturers will 
supply engineering data sheets with alternative suggest- 
ed layouts, critical dimensions, floor loading, and utility 
requirements. Some of the new multislice scanners 
require an electronics closet, which can be in the proce- 
dure room. 

Although there are slight differences between different 
models of CT scanners, generally a procedure room 18 
feet long by 14 feet wide and an adjoining room for the 
operator's console 8X14 feet will suffice (Figures 5-3 
and 5-5). 

The space planner should note that these are mini- 
mum space requirements, and larger spaces may be 
desirable. Remember that, for patient safety, sufficient 
access around the scanning unit must be maintained in 
case a patient becomes ill to allow the resuscitation team 
unobstructed access. 

The procedure room is where the scanner gantry is 
located. The patient is positioned on a table that slides 
back and forth under a rotating doughnut-like enclosure; 
some units have a gantry that tilts. The room needs a 
built-in cabinet and sink and storage for clean linen, 
patient positioning devices, contrast media, and IV mate- 
rials. A cart for soiled linen is also required. An 8-foot-long 
base cabinet with a wall cabinet or shelves above would 
be adequate. A couple of drawers might be partitioned for 
storage of alcohol preps, disposable syringes, injecta- 
bles, contrast media, tubes, tape, and emesis (vomit) 
basin. 

The ceiling of the room is normally 9 feet 6 inches high 
and the door should be at least 48 inches wide, with a 
heavy-duty closer. The walls and door will have to be lead 
shielded according to recommendations of a radiation 
physicist. 

Room lighting must be controlled by a dimmer. Indirect 
lighting around the perimeter of the room will keep glare 
out of the patient's eyes. The massive size of this equip- 
ment can be frightening to patients, even though it does 
not have exposed cables and is quite streamlined in 



286 Diagnostic Medicine 





Figure 5-54b. GE LightSpeed OX/i multislice CT scanner. (Photo courtesy: GE 
Medical Systems, Waukesha, 1/1//.) 



Figure 5-54a. GE LightSpeed" 
Waukesha, Wl.) 



OX/i multislice CT scanner. {Photo courtesy: GE Medical Systems, 



appearance (Figures 5-54a and 5-54b). A room with 
cheerful colors and a mural or back-lit film images of 
nature on the walls and/or ceiling can be quite effective in 
relaxing patients as in Color Plate 22, Figure 5-55. [Note 
that this is an old model of a GE CT scanner.] 

The room with the operator's console is where the 
technologist sits during the procedure. It must have a 
lead-shielded window facing the procedure room so that 
the patient is always in view. A typical operator's console 
is depicted in Figure 5-54a. The dimmer control for pro- 
cedure room lighting should be accessible from this 
room; however, this room also benefits from dimmer con- 



trol to eliminate glare on computer monitors. A wall- 
mounted injector control is wired to the ceiling-mounted 
IV injector in the procedure room that allows the tech to 
manually time injections of contrast medium to alter the 
appearance of vascular structures so that they can be 
imaged. 

Digital images are constructed during the scan (the 
multislice concept was explained previously) and images 
go to the network where they can be accessed by the 
radiologist for interpretation. Although older CT units that 
construct images on X-ray film may still be in use, totally 
digital formats are the norm. 



Computed Tomography 287 




Figure 5-56. Mammography room, GE equipment. {Photo courtesy: Anshen+Allen, San Francisco, CA; 
Photographer: Robert Canfield Photography.) 



MAMMOGRAPHY 

A room 10 X12 or 12 X12 feet is adequate for a mam- 
mography room. Most manufacturers' equipment is 
approximately the same size. A hand-washing sink 
should be provided in the room or just outside it to serve 
several rooms. Mammography examinations are often 
performed in a women's center or breast center, and the 
reader is referred to a detailed discussion under these 
headings in Chapter 4. 

An independent daylight processing unit may be used 
here so that the tech does not need to leave the patient 
and travel to the darkroom to process the film; however, 
in a few years it is expected that mammography units will 
be digital. Mammography equipment incorporates an 
attached leaded-glass protective screen behind which the 
operator stands. There are no unusual utility require- 
ments for this equipment, and sometimes the walls may 
not need to be lead shielded. As with any diagnostic 
imaging equipment, however, a radiation physicist must 
be consulted. 

An imaging suite having two or more mammography 
rooms may have equipment from more than one manu- 
facturer, which may alter somewhat the orientation of the 
equipment in the room. 

Indirect lighting is optimal for this type of room, and 
decorative wallpaper, carpeting, and attractive artwork 
make the patient's experience more pleasant (Figures 
4-28, 4-29, and 5-56). 



RADIATION ONCOLOGY 

Also known as radiation therapy, radiation oncology is 
designed to bombard tumors with high doses of radiation. 
This is usually an outpatient-based modality found in 
large ambulatory-care centers and sometimes in a med- 
ical office building. It is mandatory that this tenant be 
identified while the building shell is being planned. 

The room containing the linear accelerator (Figures 
5-57 and 5-58) will have concrete walls of varying thick- 



288 Diagnostic Medicine 



ness anywhere from 24 to 60 inches. The amount of con- 
crete can sometimes be reduced by the addition of steel 
or other materials. Sometimes this room can be situated 
on the site where the ground slopes (or below grade), to 
enable the room to be either partially or totally under- 
ground, reducing somewhat the radiation shielding 
requirements. 

The radiation therapy space plan in Figure 5-59 illus- 
trates the required ancillary rooms. Patients arriving for 
therapy may be ambulatory or may arrive on a gurney; 
therefore, both types of traffic must be accommodated. If 
the radiation therapy suite is part of a diagnostic imaging 
center, it is desirable to have a dedicated sub-waiting 
area for radiation therapy so that those patients need not 
wait with diagnostic radiology patients. 

The design of a radiation oncology facility is worthy of 
an entire chapter as there are so many psychological 
issues associated with the treatment as well as innovative 
design solutions. The author's book Hospital Interior 
Architecture devotes an extensive chapter to these facili- 
ties; however, the two projects included in this text are 
illustrative of the highest level of design and patient 
amenities. Color Plate 23, Figure 5-57 features a floor 
that has the warmth and appearance of wood and sug- 
gests — in what is truly a concrete bunker or tomb — that 
there are windows with beautiful views of nature as well 
as skylights with cherry blossoms overhead. These back- 
lit film images are extraordinarily beautiful and provide a 
much needed diversion for patients undergoing radiation 
therapy. The equipment in Color Plates 23 and 24, 
Figures 5-57 and 5-58 is by Siemens. The unit in Figure 
5-58 is the new Primus dual energy with multileaf colli- 
mation, which means a computer in the machine pro- 
grams the setting, thereby performing the function of what 
lead blocks and molds would have done. This will change 
the design of linear accelerator rooms because it elimi- 
nates the need for shelves or racks for lead molds and the 
requirement for a room where molds are poured. 

In the Mount Zion installation (Color Plate 24, Figure 
5-58), a PermaGrain real-wood floor (has a clear acrylic 



coating and meets all fire codes) is complemented by a 
wall of wood casework that conceals the positioning light, 
plumbing, and electronic equipment. As patients enter the 
room, their eye is drawn to back-lit panels of fabric that 
have the feeling of shoji screen. Clearly, the most dramat- 
ic aspect of the room is the ceiling designed with fiber-optic 
lights and indirect uplighting around the perimeter of the 
circle. There are five different lighting settings that change 
the color at the patient's request. 

The layout of the vault is innovative in that it address- 
es psychological issues of the patient as well as func- 
tional issues to reduce the weight of the shielded door 
which, in turn, affects the time it takes for the door, to 
open and close. There is a double-door entry so that the 
patient walks through a wooden architectural door that 
has a "soft" appearance. The gigantic, thick shielded 
door is out of view and, by the time a patient encoun- 
ters it, it is in the fully open position and the eye is 
drawn to the beauty of the ceiling. Typically, linear accel- 
erator vaults have a maze design to deflect the radia- 
tion. The entire layout of this department deserves com- 
mendation for excellent space planning: the separation 
of male and female gowned waiting, functional adjacen- 
cies of rooms, and corridors without jogs to make 
wayfinding easy. 

Dressing rooms and examination rooms need to be 
provided, along with the radiation physicist's office, 
which has a large computerized workstation, and a tech 
work area. The tech work area has TV monitors that 
allow techs to view patients in the therapy room. A large 
conference room is needed to enable the entire treat- 
ment team to meet to plan treatment for each patient. 
The physicians who work in this specialty are called 
radiation oncologists. 

Most rooms of this suite, including the linear accelera- 
tor room, may be carpeted. Other design options for the 
vault include a full-wall trompe I'oeil (fool the eye) mural 
(Color Plates 9 and 18, Figures 4-20 and 4-101, respec- 
tively), which provides a psychological escape for the 
patient. 



Radiation Oncology 289 



Sub-Basement 



MAGNETIC RESONANCE IMAGING 




MOUNT ZION COMPREHEN SIVE CANC ER CENTER 

RADIATION ONCOLOGY 



1. 


Reception 


6. 


Linear Accelerator 


11. 


Image Review 


2. 


Family Waiting 


7. 


CT Simulation 


12. 


Control 


3. 


Gowned Waiting 


8. 


HDR Imaging 


13. 


Patient Holding 


4. 


Exam 


9. 


HDR Procedure 


14. 


Nurse Station 


5. 


Linear Accelerator Control 


10. 


Hyperthermia 


15. 


Work Area / Support 



Figure 5-59. Space plan, radiation oncology. University of California San Francisco, Mount Zion Comprehensive 
Cancer Center. {Architecture and design: SmithGroup, San Francisco, CA; Photographer: Michael O'Callahan.) 



Magnetic resonance imaging (MRI) is considered by many 
to be the most revolutionary imaging technology of the cen- 
tury. Manufacturers of radiology equipment have commit- 
ted large sums of money to engineering, research, and 
product development to continually expand the capabilities 
of MRI. For example, advances in magnet technology have 
continually reduced the area of magnetic field influence 
(the Gauss field) surrounding the equipment to the point 
where it is for the most part contained within the room itself. 

This discussion will acquaint readers with the basic 
principles of MRI facility planning and design. Each man- 
ufacturer's equipment will vary somewhat in terms of 
room layout, depending on magnet weight and strength. 
Manufacturers will supply technical manuals to aid the 
architect or designer in planning the space. 

MRI uses computers and magnetic fields to provide 
noninvasive images of human anatomy. It does not 
involve radiation but, rather, uses powerful superconduct- 
ing magnets to generate magnetic fields 8000 times 
stronger than that of the earth. 

High-strength magnets (which were the only ones 
available until a few years ago) constitute a problem for 
those who are claustrophobic. The magnet — essentially 
a cube 8 feet in size — has a fairly narrow channel (the 
bore) in the center through which the patient's body trav- 
els. The "bed" that the patient lies on slides through the 
bore. It gives some individuals the feeling of being buried 
alive. As the typical scan may last 45 minutes and one is 
instructed to lie perfectly still with arms and hands folded 
across one's chest, it can be a torturous experience that 
occasionally results in panic attacks, causing the study to 
be aborted and the patient sedated. Manufacturers have 
worked hard to solve this problem by developing open 
MRIs that are lower in strength, and although they cannot 
be used in lieu of the superconducting magnets for some 
patients, they are very popular with consumers and fre- 
quently marketed to the public in local newspaper and TV 
ads (Color Plate 25, Figure 5-60, and Figure 5-61). 
Initially, when first introduced, open MRIs were weak, 
required longer scanning times, and could not perform 



290 Diagnostic Medicine 




Figure 5-61. GE OpenSpeed™ MRI. {Photo courtesy: GE Medical Systems, Waukesha, Wl.) 



Magnetic Resonance Imaging 291 





Figure 5-62. Patient wearing visor watches 3-D video to ease claustrophobia dur- 
ing MRI procedure. Figure 5-63 illustrates the view. (Photo courtesy: Resonance 
Technology, Inc., Northridge, CA.) 



Figure 5-63. Diagram of video view seen by patient. {Photo courtesy: Resonance Technology, 
Inc., Northridge, CA.) 



certain applications. The unit in Figure 5-61 is a 0.7 
tesla — one of the higher-strength open magnets — but 
these can be difficult to site as they are highly sensitive to 
vibration. They are also incredibly heavy (in excess of 
29,000 pounds) as open magnets are steel and run on 
electricity. Cryogens are not required. Some of the high- 
er-strength open magnets in development are expected 
to weigh 90,000 pounds. Open magnets are used for 
imaging the knee, shoulder, ankle, spine, and brain, and 
they can also be used to monitor stroke therapy. 

The trend is toward superconducting magnets with 
shorter bores such as the 1 .5-tesla magnet in Figure 5- 
64, which is just 54 inches in length, and even this is visu- 
ally reduced by the flared opening at both ends. The 



reduced size also results in reduced weight, which, in this 
case, is 6000 pounds. However, many of the older MRI 
units (with deep bores) will still be in service as there are 
no moving parts and the software can continually be 
upgraded. How the data are processed is the important 
issue. A dedicated phone line into the system allows the 
software to be upgraded (or remote diagnostic trou- 
bleshooting to be carried out) during the night without dis- 
ruption of patient scheduling during the day. 

Feelings of claustrophobia can be lessened in the 
large-bore magnets through the use of virtual reality. A 
patient can wear a visor that delivers 3-D video at a res- 
olution of 180,000 pixels (Figure 5-62). Obviously, it's dif- 
ficult to capture a view of the video from the patient's per- 



292 Diagnostic Medicine 



spective inside the magnet, but Figure 5-63 simulates it. 
It would be in vibrant color, of course, and integrated with 
an audio system. Soothing images and sounds of nature 
deal with another vexing aspect of MRI, namely, the noise 
generated by the machine (when current is applied to the 
copper gradient coils), which sounds like an air hammer. 
Acoustic wall treatments help to provide a quieter envi- 
ronment when the patient enters the room, which may 
lessen the patient's anxiety. Once the study is under way, 
the noise increases, and the acoustic attenuation in the 
room may not lessen the noise for the patient inside the 
bore. If this is frightening to many adults, imagine how 
traumatic it can be for children, although parents can be 
in the room for comfort, and diversions such as the virtu- 
al-reality video with cartoons may help. 

Innovation in MRI is continually advancing as digital 
technology enables ever higher levels of sophistication in 
imaging. For example, interactive software allows radiolo- 
gists to pan around the patient's anatomy in real time to 
find the most appropriate locations to image. It can also 
measure how long it takes for a contrast agent to travel 
from the point of injection to the blood vessel being stud- 
ied — physicians can do studies in real time as patients 
breathe and move. 




Planning Considerations 

Large superconductive magnets (Figures 5-64 and 5-65) 
are 1 .5 teslas and higher in strength. A number of issues 
must be evaluated before choosing the site for an MRI 
facility. 

1 . Magnet's effect on the surrounding environment 

2. Environment's effect on the magnet 

3. Corridor/door sizes for transport of magnet during 
installation 

4. Convenient access for delivery of dewars for magnet 
cryogen replenishment and for servicing the equip- 
ment 



Figure 5-64. Marconi Infinion™ short-bore 
superconducting magnet. {Photo courtesy: 
Marconi Medical Systems, Cleveland, OH.) 



Figure 5-65. Philips GYROSCAN Intera 1.5T 
MRI. (Photo courtesy: Philips Medical 
Systems North America, Shelton, CT.) 




Magnetic Resonance Imaging 293 



ir-6" 




8832MM 



EQUIPMENT 

1 OPERATOR CONSOLE 

2 COMPUTER MODULE 

3 MAGNET ENCLOSURE 

4 MOBILE COUCH/LONG TRACK 

5 TEMP. CONTROL UNIT 

6 POWER AMPLIFIER 

7 ELECTRONICS SCAN 

8 POWER DISTRIBUTION UNIT 

9 RF PENETRATION PANEL 

Figure 5-66. Typical room layout (475 square feet) for Marconi 0.23T Proview open MRI. See Figure 5-67 for 
equipment depicted in this layout. (Illustration courtesy: Marconi Medical Systems, Cleveland, OH.) 



5. Area of magnetic field influence 

6. Radiofrequency interference (RFI) shielding 

7. HVAC 

8. Power requirements 

9. Floor loading 

1 0. Storage of accessory items 

11. Interior design 

Magnet's Effect on Environment 

The influence of a strong magnetic field upon the sur- 
rounding environment must be considered, although 
today's magnets are internally shielded and the Gauss 
field is contained principally within the room as illustrated 
in Figure 5-66, which depicts the layout for the open MRI 
in Figure 5-67. For the most part, fringe fields are within 
the room, but looking at Figures 5-68 and 5-69a for super- 
conducting-strength magnets, portions of the 5-gauss field 
may fall outside the room. Figure 5-69b is a layout for a 
3.0-tesla superconducting magnet, which requires a con- 
siderably larger area (1156 square feet) compared to the 
1 .5-tesla magnet in Figure 5-69a (470 square feet). Notice 
that the 5-gauss field in Figure 5-69b is contained within 
the MRI suite of rooms. Note also that Figure 5-69a is the 
layout for the magnet in Figure 5-64. The 5-gauss field is 
the FDA recommendation for safety with respect to indi- 
viduals who have pacemakers. The Gauss field is meas- 
ured from the center of the magnet in all directions. If the 
5-gauss line extends outside the room, the area must be 
secured and a sign posted notifying passersby of the high 
magnetic field. If the area extends outdoors, it must be 
secured with a chainlink fence. When the magnet is up 
and running, the 5-gauss field must be measured and a 
report filled out and filed with regulators. 

Magnetic fields are three dimensional, extending out- 
ward on all sides, above and below, measured from the 
exact center of the magnet. Related to the magnet's maxi- 
mum operating field strength, the fringe magnetic field (the 
measurable stray field around the magnet) decreases in 
strength the farther one is from the center of the magnet. 



294 Diagnostic Medicine 



People with heart pacemakers are especially vulnera- 
ble, as are any sort of electronic or electromagnetic sys- 
tems. Information on credit cards or magnetic tapes may 
be erased. Even more sensitive are cathode ray tubes, 
image intensifiers, or other types of electronic equipment 
commonly found in diagnostic imaging systems. These 
must be kept out of the 1 -gauss line. (As a point of infor- 
mation, gauss and tesla are units of measurement of 
magnetic field strength. 1 tesla = 10 kilogauss.) 

An assessment of all adjacent areas within the influ- 
ence of the magnet is required to carefully identify the 
presence of equipment, people, or materials that may be 
sensitive to the magnetic field. 

Environment's Effect on Magnet 

The presence of ferrous material within the vicinity of the 
magnet can adversely affect the equipment's perform- 
ance. Ferromagnetic material may be either stationary or 
moving. Moving objects may include an elevator in the 
vicinity of the magnet, a passing automobile, or a piece of 
garden maintenance equipment. Structural steel beams 
and reinforced concrete in floors, ceilings, or walls are 
examples of stationary materials that may interfere with a 
distortion-free image. 

The negative effects of stationary material can some- 
times be minimized by positioning the magnet symmetri- 
cally between and/or parallel to the ferromagnetic 
objects. Shims (energized coils that provide a magnetic 
field opposite to the one causing the disturbance) are 
another method of compensating for stationary ferrous 
objects. The most critical area is the floor immediately 
under the magnet. Each manufacturer has a specification 
on the allowable number of pounds of steel in a 10-foot- 
square area under the magnet. The next area of concern 
is immediately above the magnet, namely, the direction of 
the I-beams running overhead. If diagonal, it constitutes a 
problem. The magnet should be parallel and perpendicu- 
lar to the steel in order not to disturb the magnetic field. 
High-tension power lines can also affect the magnet. 
However, one can evaluate the site with a Gauss meter to 
read the magnetic fields in the vicinity to see how best to 
site the unit. All metals have a maximum saturation, which 




Figure 5-67. Marconi 0.23T Proview open MRI. (Illustration courtesy: Marconi Medical Systems, Cleveland, OH.) 



means there is a limit as to how magnetized they can 
become. Stainless steel, for example, is at the low end 
with little potential to affect a magnet. An elevator in a cor- 
ridor outside the MRI unit constitutes a large magnetic 
field that can interfere with the magnet, especially since it 
is a moving object. 



Magnetic Resonance Imaging 295 



Figure 5-68. Suggested room 
layout for GRYOSCAN Intera 
1.5T MRI. See Figure 5-65 for 
equipment depicted in this layout. 
(Illustration courtesy: Philips 
Medical Systems North America, 
Shelton, CT.) 



PREFERRED ROOM LAYOUT 



GYROSCAN Inters 1.5T Power 




1 Gauss 

5 Gauss (Controlled Zone) 

10 Gauss 
30 Gauss 
50 Gauss 
70 Gauss 




(1) Operator Console 

(2) (2a) Emergency Run-Down Button 

(3) RF Coil Storage Cabinet 

(4) Interactive Display 

(5) Patient Support 

(6) Magnet Assembly 

(7) System Filter Panel 

(8) Patient Ventilation Fan 

(9) Main Distribution Unit 
(9a) Main Distribution Extended 



(10) Power Distribution Cabinet 

(11) System Circuit Breaker 
(11a) Chiller Circuit Breaker 

(12) Cryocooler Compressor 

(13) Neslab HX750 Chiller 

(1 4) Gradient Amplifiers 274 

(15) NT Data Acquisition Cabinet 

(16) RF Amplifier Cabinet 

(17) Gradient Heat Exchanger 

(18) Helium Dewar 



296 Diagnostic Medicine 



5 GAUSS 



Figure 5-69a. Typical room 
layout (470 square feet) for 
Marconi Infinion™ 1.5TMRI; 
equipment depicted in Figure 
5-64. (Illustration courtesy: 
Marconi Medical Systems, 
Cleveland, OH.) 




EQUIPMENT 

1 OPERATOR CONSOLE 

2 COMPUTER MODULE 

3 MAGNET ENCLOSURE 

4 PATIENT COUCH 

5 BLOWER/ COUCH EXTENSION 

6 CRYO. REFROG./ H.E. 

7 SCAN RCON/RF AMP/PDU 

8 GRADIENT CABINET #1 

9 GRADIENT CABINET #2 

10 RF PENETRATION PANEL 

11 LASER IMAGER 



4267MM 2807MM 

MAGNETIC RESONANCE 



Figure 5-69b. Typical room layout 
(1 156 square feet) for Marconi 
Infinion™ 3.0T MRI. (Illustration 
courtesy: Marconi Medical 
Systems, Cleveland, OH.) 




EQUIPMENT 

1 OPERATOR CONSOLE 

2 COMPUTER MODULE 

3 MAGNET ENCLOSURE 

4 PATIENT COUCH 

5 BLOWER/ COUCH EXTENSION 

6 CRYO. REFROG./ H.E. 

7 SCAN RECON/RF AMP/PDU 

8 SHIM CABINET 

9 GRADIENT CABINET #1 

10 GRADIENT CABINET #2 

11 l-FMRI PC RACK (OPTION) 

12 RF PENETRATION PANEL 

13 RF PENETRATION PANEL 

14 LASER IMAGER 



MAGNETIC RESONANCE 



Magnetic Resonance Imaging 297 



It is critically important to estimate, by taking physical 
measurements of the site, the influence of moving ferrous 
objects that may produce an image artifact. Each manu- 
facturer supplies an overlay grid that indicates, in con- 
centric circles, the Gauss field and indicates the distance, 
in feet, moving away from the center of the magnet. 

There are a number of other issues that should be con- 
sidered. Light fixtures within the 5-gauss field must be of 
nonmagnetic material. Fluorescent lighting must not be 
used within the R/F shielded room containing the magnet. 
Incandescent lighting with rheostatic-type light dimmers 
may be used within the magnet room, but SCR-type dim- 
mers may not be used. Commonly used medical acces- 
sory items such as oxygen cylinders, IV poles, and gur- 
neys may not be used within the 5-gauss line. Framework 
for suspended ceilings must be of aluminum. Metal studs, 
however, may be used in walls. 



Magnet Transport Access 

Consideration must be given to the transport of a magnet 
during installation. Corridor and door sizes, as well as 
floor strength, must be adequate to handle a 13,000- 
pound superconducting magnet or 29,000-pound open 
magnet. This piece of equipment cannot be broken down 
into smaller components. One might wonder how it 
arrives at the room. It is often brought through the roof or 
the side of the building. An MRI site should be planned at 
the time the medical office building is designed so that 
issues of access can be considered. It's important not just 
to get it into the room initially, but to think about how one 
would remove it through a roof hatch or an access panel 
in the exterior wall. If traveling down a corridor, the load is 
spread on 2-x12-xl6-foot-long planks of wood. 



Cryogenic Replenishment 

Superconducting magnets carry electrical current free of 
resistance only at cryogenic temperatures, necessitating 
cooling by liquid helium and nitrogen. Storage cylinders 
containing liquid helium and liquid nitrogen are called 



dewars. Facilities no longer store dewars on site because 
newer units don't need to be replenished as frequently 
and the dewars are delivered by a service as needed. It 
should be noted that although they do not show in the 
manufacturers' marketing photos, there is a cryogen 
replenishment "chimney" or turret at the top of the magnet 
and some cabling. In some models, the cryogen tube 
folds and is recessed into the machine housing (Figure 
5-64). There is also an electronic box for the gradient and 
shim coils on the side. 



Magnetic Field Influence 

As discussed previously, the extent of the magnetic field 
of influence would be determined by the size of the mag- 
net. A superconducting magnet of 1 .5 tesla has a larger 
field of influence than a less powerful one. Minimum safe- 
ty distances for objects in the magnetic fringe field must 
be carefully assessed. Inside the facility, a strict protocol 
regarding patient screening, the use of metal detectors, 
and architectural barriers can be used to protect visitors, 
as well as protect the magnet. A ferrous object in a per- 
son's pocket can become a lethal projectile if too close to 
the magnet. For this reason, it's important to provide lock- 
ers for patients' valuables, as all jewelry, wristwatches, 
wallets, and so forth must be stowed. 



Radiofrequency Interference Shielding 

There are two types of shielding in an MRI facility. One is 
shielding to contain the magnetic field (however, 
machines are currently internally shielded); the other is 
shielding from radiofrequency interference (RFI). Noise 
generated by stray radiofrequencies distorts the image. 
Any penetrations in the room, such as doors, windows, 
light fixtures, or mechanical ductwork, must be filtered to 
prevent radiofrequency interference. Some brands of 
equipment are internally shielded from RFI, thereby elim- 
inating the cost of shielding the room. There are many 
variables here; sometimes just half the room requires RFI 
shielding. 



298 Diagnostic Medicine 



HVAC 

A careful analysis of the heat output of the equipment 
must be made, and each area must be individually envi- 
ronmentally controlled so that the heat load in one room 
does not adversely affect the temperature and humidity 
of other rooms. An audible thermal alarm may be 
required in the computer room to alert the operator if the 
ambient temperature exceeds operating limits. An air fil- 
tration system may be required in the computer equip- 
ment room. Some units need chilled water for cooling the 
power supply, while others are air cooled, eliminating the 
need for water. 

A vent system must be provided to exhaust helium and 
nitrogen to the outside of the building. Precautions must 
be taken to ensure that the exit end of the exhaust duct 
does not allow gases to be vented into a closed area or 
allow access to passersby within 10 feet of the duct in 
order to protect people from cold burns. 



Power Requirements 

A power conditioner unit is a component of most MRI sys- 
tems to assure a clean, continuous power source with 
minimum fluctuation. A power management system or 
power conditioner controls electrical surges and spikes, 
which are the principal causes of computer malfunction. 



Floor Loading 

MRI magnets (superconducting) average 13,000 pounds, 
concentrated in a relatively small area. The floor space 
immediately under the magnet is of critical concern with 
respect to allowable amounts of ferrous material used in 
construction of the slab. Manufacturers' recommenda- 
tions must be carefully followed in this regard. 



Storage of Accessory Items 

A 24-inch-deep closet should be considered in the pro- 
cedure room for storage of the body coil calibration kit 



and for breast and head coils, which are heavy to carry 
around. 

Interior Design 

When MRI was first introduced, it was thought that any fer- 
rous substance would negatively affect image quality. Very 
expensive construction techniques using totally nonfer- 
rous materials were standard procedure. Wood beams, 
glued connections, stainless steel nails, Fiberglas, copper, 
and aluminum were considered appropriate construction 
materials. Now, however, manufacturers generally agree 
that shimming of the magnet is able to compensate for 
static ferrous building materials. The use of conventional 
construction techniques and materials greatly reduces the 
expense of constructing an MRI facility. 

Carpeting may be used in the examination (magnet) 
room, although it has the potential to create dust and con- 
tribute fiber particles to the air that may affect the equip- 
ment. If used, manufacturer's specifications must be 
checked to verify that the carpet has the proper amount 
of static control. The computer room will generally have 
computer-access-type flooring, making this an optimum 
condition for the installation of carpet tile. 

The ceiling height of the magnet room will generally be 
9 or 10 feet for a superconducting magnet. Ancillary 
areas will usually be 9 feet in height. 

A view of the outdoors or a garden can occasionally be 
achieved in the siting of the unit as in Color Plate 25, 
Figure 5-70. A simulated view of nature can be achieved 
with back-lit film transparencies overhead. Considering 
the cost of this equipment and the inherent fear and anx- 
iety that many patients experience, it is tragic to find 
these units placed in rooms with no interior design ameni- 
ties — with vinyl composition tile (VCT) flooring, painted 
walls, and a 2-x4-foot acoustic tile ceiling with direct 
lighting overhead. A wallpaper border does not constitute 
interior design and does nothing to relax patients. Bland, 
clinical diagnostic imaging environments are created all 
too often. It is hoped that the photo images in this book 
will stimulate a desire to go beyond this. 



Magnetic Resonance Imaging 299 



i-smr 



BLOOD GASES 



ELECTOLYTES 



CHEM1STOES 



Coao 



CftfiQAC MARKBg 




Figure 5-71. i-STAT handheld 
analyzer. {Photo courtesy: 
Abbott Diagnostics, Abbott 
Park, IL.) 



CLINICAL LABORATORY 

Laboratory tests are a vital tool in diagnosing disease. A 
basic part of a thorough examination, these studies may 
be performed in a small room within the physician's office 
or in a sophisticated clinical laboratory located within a 
medical office building, in an adjacent hospital, or in a dis- 
tant laboratory. A physician may take a blood or urine 
specimen from a patient, but send it out for testing to a 
reference laboratory. Others will do simple tests in the 
office, but send out the more complicated ones. The 
i-STAT handheld analyzer (Figure 5-71) is an example of 
what may become more commonplace in coming years 
for tests performed in physicians' offices. The instrument 
performs the following "waived" tests: prothrombin times, 
blood gases, electrolytes, glucose, and creatinine but 
does not do hematology. Refer to Chapter 3, CLIA 
Compliance, for a discussion of waived and nonwaived 
tests and how CLIA has affected what tests physicians 
ordinarily do in their offices. Currently, government agen- 
cies are establishing new regulations for physician-oper- 
ated laboratories. 

The designer of a medical office building will most 
often encounter small clinical labs. Large labs, employing 
a pathologist, will usually be designed by a lab specialist 
experienced in the planning of such facilities. It is unlikely 
that a large clinical lab will be included in a medical office 
building if that building is adjacent to a hospital. 
Sometimes a "drawing station" will be provided in an MOB 
with specimens processed and tested at another location 
(Figure 5-72). This discussion, then, is limited to introduc- 
ing the reader to basic laboratory processes and space 
requirements — some of which will occur in a small labo- 
ratory facility. 



CLIA and Other Regulations 

The Clinical Laboratory Improvement Act (CLIA), report- 
ed in the Federal Register, imposes strict regulations on 
laboratories, some of which may affect design but mostly 



deal with processes and procedures, safety, billing, 
record keeping, and the like. At the outset of a project, it's 
important to understand the requirements for accredita- 
tion and licensing by a potential number of agencies. In 
addition, as can be expected, OSHA has many standards 
and regulations that assure the safety of laboratory per- 
sonnel. 



Development of the Requirements 

As with all medical suites, the success of a well-designed 
laboratory is dependent on a thorough understanding of 
needs — a written description of all requirements that 
must be incorporated into the design. 
The following checklist will serve as a guide: 

1 . List the procedures that are to be performed. They will 
vary with the medical specialties of the building's ten- 
ants. 

2. Analyze the space in terms of projected equipment 
and personnel in three areas: 

a. Administrative. 

b. Technical. 

c. Support (includes washing, sterilization, biohaz- 
ardous waste storage, reagent and supply stor- 
age, computer hardware, clean and dirty lab 
coats, lockers, and laboratory records). Storage is 
required at workbenches for manuals, dispos- 
ables, and constantly used items. Open shelves 
and closed storage are required. 

3. Review sizes and specifications of major pieces of 
equipment. Tabulate the lineal feet of high and low 
countertop space required for each item or area and 
note required adjacencies. Determine if equipment 
will have special plumbing, electrical, and tempera- 
ture requirements. 

4. Determine which procedures may be combined in the 
same work area and which require separate areas 
(Figure 5-73). 



300 Diagnostic Medicine 



J- 



22'-6' ; 



-^ 



o 
J 

oo 

CM 










WAITING ROOM 





1 ' 

L ' J 



1 ' 




PRINTER 

ACCESSIONING 



FAX 



PHLEBOTOMY 



FILE 



FULL HT. 
FRIDGE/FREEZER 



I I 



PROCESSING 
LAB 



HANDWASH! 
SINK- 




LA£*f*A-rwr- 




Figure 5-73. Schematic diagram of clinical laboratory. 



-X— 

LAB BLOOD DRAWING STATION 

630 SF 
Figure 5-72. Space plan for laboratory blood-drawing station, 630 square feet. (Design: Jain Malkin Inc.) 



Clinical Laboratory 301 



5. Divide technical areas by functional units: hematology, 
chemistry, microbiology, urinalysis, serology, but the 
trend is to avoid (except for microbiology) enclosing 
them with walls; an open area is more flexible. 

6. Estimate the volume of tests in each functional unit in 
order to determine the number of tech workstations 
required. 

7. Review desirable functional adjacencies. For exam- 
ple, urinalysis can be combined with either chemistry 
or hematology. Hematology can be located near the 
blood drawing area since those specimens do not 
require additional processing prior to analysis. Due to 
the prevalence of disposables and premade 
reagents, the amount of glassware has been greatly 
reduced. If the laboratory does need a glass-wash- 
ing/sterilization area, it should be located near micro- 
biology or chemistry. Small laboratories have a limit- 
ed staff; therefore, technical modules need to be 
clustered together so that staff working in each unit 
can support each other. 

8. Allow for future expansion. If any units are expected to 
expand in terms of physical space, they would best be 
located in the area of the suite adjacent to the labora- 
tory and where expansion may easily occur without 
infringing upon existing critical office functions. 

9. Review utility requirements for all equipment carefully. 
Separate electrical circuits are required for many 
instruments in order to avoid fluctuating voltage, 
which adversely affects the accuracy of the instru- 
ments. During construction, it is a good idea to leave 
room in the panel for future power requirements and 
potential need for a 220-volt circuit. 

10. Determine which equipment and space, if any, will be 
shared among departments. Depending on the size 
and volume of testing performed in the laboratory, 
either common-use or dedicated refrigerators, freez- 
ers, computer terminals, and clerical space will be 
needed. In some space plans and based on workflow, 



the refrigerators and freezers may be "banked" 
together in a location convenient to all departments. 
These may need to be anchored to the wall in earth- 
quake-prone areas. The refrigerator is a wide, deep 
restaurant type with glazed doors, and the freezer an 
upright model. 

1 1 . Allot storage space for supplies used on a daily basis 
in each technical module. A storage room would be 
used for bulk purchase of supplies. 

12. Consider environmental factors such as ventilation, 
light, and isolation of equipment that may be noisy or 
produce heat when used. 



Technical Modules 

The following descriptions of technical modules will 
familiarize readers with standard methods of processing 
samples. Electronic, automated clinical analyzers are 
widely used even by small labs. Instrument manufactur- 
ers in recent years have designed automated equip- 
ment specifically for this market, the price of which has 
been brought in line with what the small laboratory 
can afford. Newer equipment is often capable of per- 
forming a variety of tests that formerly required several 
instruments. 

Hematology. This is the study of the cellular components 
of blood. Procedures performed in this area are those 
most frequently ordered by a physician such as CBCs 
(complete blood counts); thus, this module should be 
located close to the phlebotomy (blood drawing) station 
for most efficient workflow (Figure 5-74). 

One half of the module should be set aside for proce- 
dures such as sedimentation rates (a level, stable work 
surface is needed), the hematology analyzer, and slide 
staining. Another portion of the work surface (at 30-inch 
height) should have knee space for sit-down work at the 
microscope. If there is a microhematocrit centrifuge 



302 Diagnostic Medicine 



60'-0" 



BIOHAZARDOUS 
WASTE 



ANALYZER 




STORAGE 



MICROBIOLOGY 
HOOD 



CLINICAL LABORATORY 



2400 SF 
Figure 5-74. Space plan for clinical laboratory, 2400 square feet. (Design: Jain Malkin Inc.) 



Clinical Laboratory 303 





Figure 5-75. SPINCHRON® DLX centrifuge. (Photo 
courtesy: Beckman Coulter, Inc., Brea, CA.) 



Figure 5-76. Cell-Dyn® 3200 hematology analyzer. (Photo courtesy: Abbott Diagnostics, Abbott Park, IL.) 



(Figure 5-75), due to its noise and vibration when in use, it 
should be placed in an area where it will not disturb anyone 
or interfere with the microscopic examination of slides. In a 
small-volume lab, a refrigerator/freezer, desk, and comput- 
er terminal (if applicable) should be centrally located for use 
by hematology, urinalysis, and chemistry. Critical adjacen- 
cies of equipment are dependent on staffing and whether 
one tech is doing a few tests in each area. If, because of the 
physician mix or the presence of an ambulatory surgical 
center, coagulation tests, such as prothrombin time, are to 
be done, they would be performed in this unit. Additional 
benchtop space would be needed for a coagulation 
instrument and a high-speed centrifuge. The hematology 
analyzer is often a benchtop instrument (Figure 5-76). 

Chemistry. A variety of chemical procedures are per- 
formed here. Most manual testing is done at a 34-inch- 
high countertop, but a lowered knee-space area should 
be provided for seated procedures or benchtop instru- 
ments. There should be floor space for larger multitest 
instruments in laboratories supporting a large number of 
physicians (Figures 5-77 and 5-78). One countertop will 



have open shelves above for chemicals used during pro- 
cedures and for disposables and constantly used items. 
However, these shelves should have a protective barrier 
such as a 3-inch-high Plexiglas band at the edge to pre- 
vent the fall of items in case of an earthquake or accident. 
A sink is required in the chemistry work area, and built-in 
cabinetry would consist of drawers and hinged-door stor- 
age below the countertop. It is useful if the bottom draw- 
ers in a few locations are file drawers to keep frequently 
used references at hand. Ninety percent of the specimens 
are blood; 10 percent are urine. 

An instrument table or countertop should be available for 
small instruments or manual tests. The area will require 
countertop space for a centrifuge. Depending on the volume 
of work performed in the laboratory, this centrifuge could 
be shared by specimen processing, if adjacencies exist. 

Urinalysis. This unit may be located in the hematology or 
the chemistry module. One half of the urinalysis work 
counter is used for microscopic examinations and the 
other half for chemical procedures. The work surface 
should be 30 inches high and have a sink. 



304 Diagnostic Medicine 




Figure 5-77. aca® Star™ chemistry analyzer. {Photo courtesy: Dade Behring, Inc., Deerfield, IL.) 



Serology and Microbiology. Serology is the study of 
serum and the body's immunological response to dis- 
ease. Microbiology is the study of infectious organisms. 
These units may be combined. Parasitology, the study of 
parasites (normally performed on feces), is included in 
the microbiology module. Since most work is done in a 
seated position, the countertop should be 30 inches high 
with a knee space for the technologist, space for a cen- 
trifuge, and open shelves above for reagents. A refrigera- 
tor is needed for the storage of purchased media and 
reagents. Floor or countertop space must be allocated for 




Figure 5-78. SYNCHRON LX® 20 
chemistry analyzer. (Photo courtesy: 
Beckman Coulter, Inc., Brea, CA.) 



Clinical Laboratory 305 



both a 37 degree Celsius incubator and a C0 2 incubator. 
A sink is needed for staining slides and for hand washing. 
As with other technical modules, drawers and under- 
counter cabinets are necessary. 

Although few small labs will do microbiology, it should be 
noted that a microbiological hood is required to prevent the 
spread of infection during preparation of specimens for 
tuberculosis, fungi, viruses, bacteria, or parasite isolation 
and identification. This HEPA-filtered biological safety cab- 
inet (hood) may or may not require venting to the outside, 
depending on the model and health regulations. If at all 
possible, separate the microbiology module from other 
modules by full-height partitions to reduce contamination 
of air and the chance of infection being transmitted to other 
lab personnel. A window in the door is a good idea to see 
if someone is working in the room and to prevent the occu- 
pant from feeling isolated while in the room. A new law may 
require an anteroom or vestibule air interlock. 

Histology. This is the study of tissues. Thin slices of dis- 
eased specimens are examined by microscope. During 
surgery, for example, sections of tumors would be sent to 
a hospital for a pathologist's report on possible malignan- 
cy or other cellular deformities. Small labs in a medical 
office building would not have a histology unit or a pathol- 
ogist. Normally, this work would be performed in a hospi- 
tal or reference lab. Thus, the requirements in equipment 
and work space will not be discussed here. 



tests on the specimen and produce a printed result form. 
Large analyzers can process upwards of 180 tests per 
hour with little manual intervention. Many analyzers have 
RS232 ports, which allow results to be sent directly to the 
laboratory computer. Some analyzers fit on a countertop 
(Figure 5-76), whereas others require floor space 
(Figures 5-77 and 5-78). 



Accessioning of Specimens and 
Processing Area 

The lab should have an area designated for accessioning 
(recording) of specimens and tests to be performed. 
Recording may be done manually or by computer. If done 
manually, there should be an area in each module for per- 
forming paperwork. This is where labels are printed for 
specimen vials with patient's name and identification 
number. 

Generally, a laboratory will need an area for the pro- 
cessing of specimens that are to be tested later or sent to 
an outside laboratory. A countertop area large enough to 
accommodate a centrifuge, specimen containers, test 
tube racks, a computer, and clerical functions is neces- 
sary. This area is usually located near where the speci- 
mens first arrive in the laboratory. A refrigerator and 
freezer are also needed for specimen storage awaiting 
pickup. 



Automated Analyzers 



Central Communication Center 



Many laboratories now have microprocessor-based 
hematology and chemistry analyzers, which considerably 
reduce the number of technologists required and elimi- 
nate much of the equipment necessary for manual analy- 
sis. Automated analyzers vary considerably in their size 
and capabilities. All of them are aimed at speed and total 
automation, freeing the technologist to walk away while 
samples are being tested. 

One may place a blood specimen into the machine, 
and in a few minutes, the analyzer will complete multiple 



The modern laboratory is directly linked by computer to 
physicians' offices and to reference laboratories. 
Communication into and out of the laboratory is of critical 
importance. Depending on the size of the laboratory, one 
or more phones should be available for reporting results. 
A personal computer may be used for laboratory record 
keeping. If the lab sends out a substantial amount of work 
to a reference laboratory, a CRT and printer allow quick 
access to specimen results from the reference laboratory. 
This is best located at a desk convenient to all of the tech- 



306 Diagnostic Medicine 



nical modules. In Figure 5-74, it is located in the process- 
ing area. In the future, laboratories may use the Internet 
to connect with reference laboratories and physicians for 
ordering tests and reporting test results. 



valves that allow the handles to be removed so the 
patient cannot dilute the specimen with water. A colored 
dye is also added to the water remaining in the bowl so it 
cannot be used. 



Administrative Area 

The administrative area consists of waiting room, busi- 
ness office/reception room, staff lounge and locker room, 
and, sometimes in a large laboratory, a private office for 
the director or manager of the lab. These areas should be 
separated from the clinical areas so that non-lab person- 
nel need not enter the clinical work space. 

Dressing Area for Employees. A lab will often include 
lockers and a dressing area where technicians may 
change clothes. A staff toilet room at this location is con- 
venient. The dressing area may be combined with the 
staff lounge. Since food cannot be stored or eaten in the 
lab, it is important to provide a room to be used for breaks 
and lunch. This area should also contain an area for clean 
lab coats and a linen hamper. There should be a location 
for hanging up coats being worn so that they are left out- 
side the lunch room. 



Specimen Toilet 

The toilet room for collection of urine specimens should 
have a small pass-through in the wall (see the Appendix) 
that opens into the clinical area so that urine samples can 
be picked up by the technician without the patient having 
to carry the cup out of the bathroom. This toilet room, as 
in any medical or dental suite, should be designed to 
accommodate the handicapped. 

Drug-Testing Toilet Design 

If there is a need for the collection of "chain of custody" 
drugs of abuse urine specimens, a "dry" toilet needs to be 
created. This requires a mechanism for shutting off the 
water to the sink and toilet. A plumber can install shut-off 



Blood Drawing 

Blood drawing (phlebotomy) can be performed in a small 
room or cubicle equipped with a straight chair and a 
24-x36-inch table or a prefabricated specialized blood 
drawing chair (Figures 3-49 and 5-79). Privacy is impor- 
tant. If individual rooms or enclosures are not possible, a 
screen or cubicle drape will protect those waiting from 
the view of blood being drawn and provide privacy if 




Figure 5-79. Blood draw chair. (Photo courtesy: Midmark Corporation, 
Versailles, OH.) 



Clinical Laboratory 307 



clothing needs to be removed to access the arm. If space 
allows, it is a good idea to have one private cubicle large 
enough to accommodate a built-in bed or bench for 
drawing blood of patients who may feel faint and for 
babies or small children. A sink is needed in the area so 
phlebotomists can wash their hands between patients. 
This is a good location for a rack to hold glove boxes 
(Figure 3-43). 



Auxiliary (Support) Services 

Disposal of Biohazardous Waste. Regulations for the 
disposal of biohazardous waste dictate that an area be 
allocated for the storage of laboratory specimens, dis- 
posable supplies, needles, syringes, and other items that 
may have come into contact with patient specimens until 
these contaminated items are collected by licensed dis- 
posal companies. Presently, OSHA standards require 
storage in sharps containers or red bags placed in 
leakproof secondary containers. A secured labeled area 
is required for storage until pickup. The soiled utility room 
can be used for this purpose. 

The laboratory has the option, however, of autoclaving 
its infectious waste prior to its being picked up by the stan- 
dard refuse collection agency. If the laboratory chooses 
this option, an additional space large enough to accom- 
modate this equipment will be required in the sterilization 
room. Criteria for the handling of hazardous materials (i.e., 
potentially carcinogenic or infectious waste) must be 
reviewed before designing a laboratory that must meet 
certification and licensure requirements. 

Glass Washing and Sterilization. Today, with the use of 
disposables and premade reagents, the need for a glass- 
washing and sterilization area has been almost eliminat- 
ed. This area used to be larger when lab procedures 
were done manually. This module, if required, should be 
located near microbiology or chemistry. This unit may 
contain deionized water equipment, sterilizer, drying 
oven, and pipette washer, depending on the laboratory's 
test volume and mix of procedures. Storage of glass- 



ware, chemicals, reagents, and paper supplies should be 
provided in cabinets. A ventilation hood over the steriliz- 
ers would exhaust heat and moisture generated by the 
equipment. 

Record Storage. Due to the increased volume of 
records, which need to be maintained for several years, 
file cabinets and an area for storage of old records should 
be provided. These records include requisitions (as a 
backup for billing to Medicaid and Medicare), instrument 
printouts, equipment service records, and quality control 
reports. 



Future Technology 

As with any medical space, there should be some flexibil- 
ity in the layout to allow for future space requirements as 
technology evolves. 



Utilities 

A clinical lab may require gas tanks. External cylinders of 
C0 2 are needed for the incubator in microbiology. Acid- 
resistant material for plumbing drains and the U-joint is 
recommended for sinks that will be used for reagent dis- 
posal. Also, sinks should have plaster traps. Depending 
on the volume, the substance, and local wastewater reg- 
ulations, most laboratory waste can be discharged into 
the sewer. Devices to prevent backflow are required. It is 
important to know local codes regarding requirements 
for waste disposal. Laboratory sinks should be of a non- 
corrosive material and countertop work surfaces may be 
chemical-resistant plastic laminate or special ceramic 
lab tops. 



Air Conditioning and Ventilation 

The need for a well-planned, functional air-conditioning 
and ventilation system is critical in a laboratory. Chemical 



308 Diagnostic Medicine 



fumes, vapors, gases, heat from equipment, plus the 
impracticality of open windows, create a health hazard to 
those in adjacent medical suites as well as to the labora- 
tory staff who suffer repeated exposure. It is not adequate 
simply to exhaust these vapors out of the roof of the build- 
ing without considering the dispersion to nearby persons 
and buildings. 

Ventilation requirements for each work unit must be 
studied so that airflow patterns can be regulated by 
proper location of supply and exhaust grilles. A compe- 
tent mechanical engineer should be consulted to pre- 
pare this study. Exhaust air from fume hoods should be 
conducted through noncorrosive ducts to the roof of the 
building and not be recirculated. The microbiology mod- 
ule should have negative air pressure in relation to sur- 
rounding rooms. In addition, slightly negative air pres- 
sure between the lab and the medical building should 
be maintained in order to prevent odors and contami- 
nants from spreading. 



Power Requirements 

A laboratory demands maximum flexibility; thus, each 
work surface countertop should have a continuous plug- 
mold strip and a separate circuit every 8 to 10 feet. 
Because certain pieces of equipment may draw as much 
as 15 amperes when warming up, a careful inventory 
must be made of the power requirements of each major 
piece of equipment. Automated analyzers are sensitive to 
voltage fluctuations and may require a constant voltage 
regulator as well as a separate circuit. [It should be noted 
that a centrifuge or shaker should not be put on a count- 
er where the vibration may interfere with a computer 
screen.] 

Work areas need shadow-free light, requiring that a flu- 
orescent "shelf" light be mounted below the upper cabi- 
nets. Otherwise, light may be supplied totally by ceiling- 
mounted fluorescent luminaires in sufficient quantity to 
assure a level of at least 100 footcandles for close work 
and 50 footcandles for general illumination. 

Consideration must be given, when designing and 



specifying lighting, to the elimination of glare from data 
management display monitors associated with clinical 
analyzers. This may necessitate indirect lighting that 
bounces off the ceiling for general illumination. The issue 
would be the same as that encountered in any office 
where computer monitors are in use. 



Interior Design 

For years, laboratories have been designed in a neutral 
color palette because the reflection of colors made it dif- 
ficult to match samples to a standard or to analyze colors. 
Today, with automated equipment, matching of speci- 
mens to a standard is no longer done visually. Walls may 
be any pleasant color the technologist prefers, and subtle 
patterns may be considered for plastic laminate counter- 
tops. The floor might have an attractive design created 
with several colors of vinyl composition tile or it may be 
sheet vinyl with a confetti pattern. 

In the laboratory area, there needs to be wall space for 
white boards and bulletin boards in the modules. These 
provide space for messages to other staff members, 
posting of quality control charts, and changes in test pro- 
cedures. 

In patient areas, provide a place where patients can 
hang their coats, handbags, and stow their packages or 
briefcases. This should be located principally in the 
blood-drawing area. The waiting room needs a secure 
place for hanging overcoats and umbrellas and for stow- 
ing boots. 



Small Laboratory 

The small laboratory, which may be part of a group-prac- 
tice suite, would perform the more common and simple 
laboratory tests. (This is also known as a stat lab, 
because the tests are generally urgently required.) 
Specimens requiring complex bacteriological or chemical 
procedures would probably be sent to an outside labora- 
tory. Biopsied tissue specimens would be sent to a 



Clinical Laboratory 309 




pathologist for diagnosis. Thus, the small lab (650 to 750 
square feet) would have separate areas for hematology, 
chemistry, urinalysis, and possibly microbiology, allowing 
approximately 8 lineal feet of countertop for each, plus 
two blood draw cubicles, specimen toilet, small recep- 
tion/waiting area, storage room, and glass-washing/ ster- 
ilization area. With the continuing development of small 
multipurpose analyzers and "waived" tests requiring min- 
imal work space, small laboratories may require less 
space in the future. The small benchtop analyzer in 
Figure 5-80 does routine chemistry tests. It is low volume 
and hand-fed and may be found in physicians' offices in a 
stat lab. The i-STAT (Figure 5-71) may also be used in a 
stat lab. 



Figure 5-80. Cobas MIRA Plus benchtop chemistry analyzer. {Photo courtesy: Roche Diagnostics, 
Indianapolis, IN.) 



310 Diagnostic Medicine 



CHAPTER 6 

Group Practice 



The focus of this chapter is the small to medium-sized group 
practice — 8 to 20 physicians. Large ambulatory-care net- 
works, such as the Mayo or Cleveland Clinic or the 1 00,000- 
to 1 50,000-square-foot hospital-based ambulatory facilities 
that have become so common in the past 10 years on med- 
ical center campuses, are far too complex to cover in one 
chapter. These facilities grow out of a context of politics (rela- 
tionships between physicians and hospitals as to what 
departments will be included and how the revenue is to be 
divided); an analysis of market share; and a sophisticated 
master planning process that involves workload analysis 
using computer programs to model various scenarios, ana- 
lyze revenue stream, allocate space by department, and 
estimate construction cost. Nevertheless, this book will be 
helpful at the micro level, as each department is planned, 
since the basic composition of each specialty suite and the 
layout of typical rooms, as well as the equipment used, will 
be relevant. In addition, the many patient-centered features 
and design ideas will be useful. The reader is reminded to 
read Chapters 3 and 4 as background for Chapter 6. These 
include a discussion of digital technology. 

The point of origin for all group practices is the Mayo 
Clinic. Founded in 1897, it became the prototype for others 
that followed, including the prominent Menninger Clinic in 
Topeka.The Mayo Clinic is reputed to be the world's largest 
medical clinic. While few aspire to this level of achievement, 
many of the principles upon which the Mayo Clinic was 
founded apply to smaller group practices as well. These 
include the sharing or pooling of knowledge, a division of 
labor that allows physicians to concentrate on their special- 
ty, and a desire to stay on the cutting edge of new technol- 
ogy. It is a teamwork approach to the delivery of medicine. 

There is an ever-increasing trend toward group practice. 
Economics and the threat of for-profit chains dominating the 
market have encouraged many solo practitioners to band 



together in groups to enhance their strength and presence. 
Moreover, group practice offers physicians better managed- 
care contract negotiation power. Although some physicians 
do not feel psychologically geared to practice in a large 
organization, and some fear a loss of individual authority in 
medical matters, group practice does increase a physician's 
productivity and may lower the cost of healthcare. 

In theory, each physician can be made more productive by 
eliminating the waste and inefficiencies inherent in a solo 
practice. A solo practitioner may work a 60- or 70-hour week, 
but perhaps 20 percent of his or her time is spent on office 
management. A group practice provides a division of labor 
with sufficient personnel to perform these nonmedical tasks, 
thereby enabling physicians to concentrate solely on practic- 
ing medicine. 

Another advantage of group practice is the conven- 
ience of having a fully staffed radiology department and 
clinical lab in the physician's own office. Equipment that 
might be too costly or underutilized in the small medical 
office can easily be justified in a large group practice. 
Other benefits of a group practice are greater freedom 
with regard to leisure time. Partners can cover for one 
another with no lack of continuity in care for the patient. 
And physicians in a multispecialty group provide one 
another with immediate access to specialists in other 
fields. This pooling of resources provides patients more 
efficient and complete professional services than each 
physician could provide individually. 

Of course, economics plays a prime role in motivating 
physicians to practice together. Eight physicians in private 
practice would require eight business offices, eight waiting 
rooms, possibly six to eight X-ray rooms, six to eight minor 
surgery rooms — a great duplication of space and personnel. 
Together, as a group, the eight might have two minor surger- 
ies, two X-ray rooms, one large waiting room, and one cen- 



311 



tralized business office. More efficient use of space and 
personnel means more take-home profit for physicians 
and perhaps lower costs for patients. In addition, certain 
lab tests or X-rays that might otherwise be sent out could 
be done within a properly equipped suite, netting extra 
fees for the group practice to reduce office overhead, pro- 
viding CLIA regulations are met. Refer to Chapter 3 for a 
discussion about why physicians currently do little lab 
work within their offices, and to the Introduction for infor- 
mation about HIPAA. 

As healthcare approaches the status of a commodity, the 
pressure on group-practice physicians to meet revenue 
goals (with compensation often tied to productivity) has 
steadily increased. The group-practice model that once 
sheltered physicians from some of the minutiae of private 
practice has imposed its own sort of tyranny, which, as 
reimbursement steadily decreases, enslaves them to "beat 
the clock," seeing ever greater numbers of patients and 
enjoying it less. In past years, the billing of ancillary servic- 
es helped to compensate for declining professional fees as 
managed care continued to dominate the marketplace. 
However, CLIA regulations and the Stark statute (relates to 
physician self-referral regulations) have made it difficult to 
vertically integrate ancillary services to enhance physi- 
cians' income without tripping over conflict-of-interest 
issues and ever more complex compliance requirements. 



STARK STATUTE 
Stark I 



other services. Proposed regulations on Stark II, issued in 
1998, were considered by many to be confusing and 
ambiguous, prompting the Health Care Financing 
Administration (HCFA) to issue important changes in the 
Stark II final rule as a response to formal hearings and crit- 
icism. The definition of group practice has been broadened 
in terms of what qualifies as a "single legal entity," and pro- 
ductivity bonuses and profit-sharing rules have been 
revised. Significant changes were made to the "in-office 
ancillary services" exception to ownership and compensa- 
tion arrangements. The final rule, divided into Phase I and 
Phase II, is reported in the January 4, 2001 Federal 
Register. Phase I became effective January 4, 2002. 



ACCREDITATION 

At the start of programming, the space planner must 
determine the type of certification, accreditation, or 
licensing the group is seeking. Some regulatory agencies 
have requirements that affect space planning and design 
(Medicare certification, for example), while others deal 
with issues of governance, credentialing, quality manage- 
ment and improvement, and clinical records. Periodic on- 
site surveys and peer review occur. These agencies may 
include JCAHO (Joint Commission on Accreditation of 
Healthcare Organizations), AAAHC (Accreditation 
Association for Ambulatory Health Care), and a number 
of organizations that accredit managed care enterprises. 
Refer also to Chapter 4 and Chapter 7 for additional dis- 
cussion of these issues. 



Named after California senator Pete Stark, this statute 
creates penalties for physicians who engage in self-refer- 
ral of Medicare patients to clinical labs in which they have 
a financial interest. Known as Stark I, the legislation was 
enacted by Congress in 1989. 

Stark II 

Stark II, enacted by Congress in 1993, prohibits self-refer- 
rals for radiology, hospital inpatient/outpatient, and eight 



TYPES OF GROUP PRACTICES 

There are four types of group practices in terms of space- 
planning considerations. The single-specialty group con- 
sists of physicians (rarely more than eight) who are all of 
the same medical specialty. This type of group permits a 
physician a great deal of freedom since patients usually 
will accept treatment from any member of the group. This 
allows for better utilization of all the doctors' time. The sin- 
gle-specialty group represents two-thirds (67 percent) of 



312 Group Practice 



the market.* This includes family practice and internal 
medicine. 

The multispecialty group (33 percent of the market)^ 
might typically be a large clinic offering internal medicine, 
OB-GYN, urology, pediatrics, family practice, ENT, or any 
combination of medical specialties. A group such as this 
could potentially offer many of the outpatient services 
provided by a hospital: clinical lab studies, diagnostic 
radiology, physical therapy, chemotherapy infusion, 
endoscopy, and multiphasic medical screening. A multi- 
specialty group might consist of 20 physicians to several 
hundred physicians as in an HMO. 

The internal medicine group might be a group of gen- 
eral internists plus those with various subspecialties: pul- 
monary medicine, cardiovascular disease, hematology, 
oncology, gastroenterology, or endocrinology. A large 
enough group could support its own clinical lab, radiology 
department, cardiovascular rehabilitation, and pulmonary 
function testing. 

The family practice group enables primary-care 
physicians to expand beyond their individual resources 
in purchasing equipment and staffing an office. Large 
family practice groups are often found in small towns, 
and sometimes they have one or more specialists on 
staff in an effort to offer the community a wider range of 
services. 



PRIMARY-CARE CLINICS 

The primary-care clinic is an extension of the family prac- 
tice group, which, depending on the extent of ancillary 
services, can be quite large and self-sustaining. As an 
example, both of the primary-care clinics in Figures 6-1 
and 6-2 and 6-3 and 6-4 have been set up to contract with 
insurance companies to provide total care for patients on 
a capitated (fixed amount per month) basis. There is every 
incentive to keep patients out of the emergency (ER) and 



*SMG Market Letter, January 2000, Chicago, 
"hbid. 



out of the hospital, since that cost comes out of the med- 
ical group's prof it. Therefore, both of these clinics have an 
urgent-care unit to observe and treat patients who might 
otherwise go to the ER. They also offer fairly extensive 
diagnostic imaging and lab services. Physicians in these 
clinics are salaried employees, a number of whom would 
have a financial interest in the enterprise. 

In Figure 6-1, registration, ancillary services, and 
urgent care are on the first floor with direct gurney access 
from urgent care to the exterior. Radiology has a direct 
entry into urgent care. On the second floor (Figure 6-2), 
generic clinic modules accommodate a variety of practi- 
tioners. The clinic is designed for after-hours security 
when everything is locked except access to urgent care, 
radiology, and lab. 

In Figure 6-3, the first floor includes central registration, 
medical records (with a dumbwaiter to urgent care 
above), staff lockers and lounge (also serves for in-serv- 
ice training, conferences, classroom), and three generic 
primary-care modules. The second floor, Figure 6-4, has 
urgent care, lab, diagnostic imaging, pediatrics, OB-GYN, 
and administration. [One might wonder why urgent care is 
not located on the first floor. In reality, neither floor is on 
grade — they are the second and third floors of an MOB.] 

The hybrid nature of primary-care clinics can be illus- 
trated by Figures 6-5 and 6-6, which, in addition to the 
expected components, feature, respectively, a medical 
oncology unit and a diagnostic breast center. A unique 
example of adaptive reuse, the 30,000-square-foot free- 
standing St. Francis Hospital community health center 
(Figure 6-5) was converted from a 30-year-old former 
supermarket. Exploiting the high ceilings with a playful 
trellis and colorful fabric panels, it has an upbeat 
ambiance (Color plate 26, Figure 6-7). The reader may 
wish to refer to Figure 4-50 for a view of the medical 
oncology waiting area and resource center in this facility. 

Centralized waiting and registration areas lead 
directly to four primary-care pods and to diagnostic 
imaging in Figure 6-6, while the breast center has its 
own entry and well-appointed waiting room (Color Plate 
26, Figure 6-8). 



Primary-Care Clinics 313 



NOTE: NO GENERAL ANESTHESIA 
USED IN THIS SURGERY SUITE. 



STAFF WORK CORRIDOR KEEPS PATIENTS 
AWAY FROM FILM PROCESSING AREA AND 
ALLOWS FOR GREATEST STAFF EFFICENCY. 




STAFF CAN PICK UP URINE AND BLOOD 
SPECIMENS WITHOUT LEAVING LAB 
PROCESSING AREA. 



MISSION PARK 
CLINIC, 50,000 SF 
PRIMARY CARE 



ADEQUATE CIRCULATION SPACE IS PROVIDED 
AROUND SEATING; GROUPINGS HAVE BEEN 
ARRANGED TO MINIMIZE PATIENTS STARING 
AT EACH OTHER AT CLOSE PROXIMITY. 



URGENT CARE IS ADJACENT TO RADIOLOGY; 
PATIENT CAN BE TRANSPORTED INTERNALLY 
TO RADIOLOGY; AFTER-HOURS PATIENTS 
VISITING URGENT CARE CANNOT GAIN 
ACCESS TO REMAINDER OF SUITE. 



FIRST FLOOR PLAN 



n_r"L_n r 

2 10 FLET 20 




Figure 6-1. Space plan for 50,000-square- 
foot primary-care clinic. Also see Figure 6-2. 
(Design: Jain Malkin Inc.) 



314 Group Practice 




DECENTRALIZED PODS OF EXAM ROOMS, 
NURSE STATION, AND CONSULT SAVE STEPS 
AND MAXIMIZE PHYSICIAN/PATIENT/NURSE 
INTERACTION. 



LARGE, OPEN RECEPTION DESKS (WITHOUT 
SLIDING GLASS ENCLOSURE) MAKE PATIENTS 
FEEL WELCOME. MAINTAINING VISUAL 
CONTACT MAKES THEM FEEL LESS ANXIOUS. 



MISSION PARK 
CLINIC, 50,000 SF 
PRIMARY CARE 



SEPARATION OF INCOMING AND OUTGOING 
PATIENTS PROVIDES PRIVACY FOR THE 
PATIENT TO DISCUSS A FINANCIAL MATTER 
AND ALSO ELIMINATES CROSS TRAFFIC 
CONGESTION IN A HIGH-VOLUME PRACTICE. 



SECOND FLOOR PLAN 



ru-Ln 

2 10 FEET 




Figure 6-2. Space plan for 50,000- 
square-foot primary-care clinic. 
Also see Figure 6-1 . (Design: Jain 
Malkin Inc.) 



Primary-Care Clinics 315 




PRIMARY CARE CLINIC - FIRST FLOOR 

30,000 SF ON TWO FLOORS 

Figure 6-3. Space plan for 30,000-square-foot primary-care clinic. Also see Figure 6-4. (Design: Jain 
Malkin Inc.) 



316 Group Practice 




PRIMARY CARE CLINIC - SECOND FLOOR 

30,000 SF ON TWO FLOORS 

Figure 6-4. Space plan for 30,000-square-foot primary-care clinic. Also see Figure 6-3. (Design: Jain 
Mai kin Inc.) 



Primary-Care Clinics 317 




EDUCATION 
•CENTER 



PRIMARY CARE MEDICAL CENTER 



He ids St c dics 



Figure 6-5. Space plan, St. Francis Hospital Primary Care Medical Center, Morton Grove, IL, 30,000 square feet. 
(Architecture and interior design: Mekus Studios, Chicago, IL.) 



o v a' 



16' 



32' 



n 



318 Group Practice 



* nnn 


o 


fl 




31 
7> 


cr^ 


15 


L«U 


E 


ng 


b 



1 LOBBY 

7 WAITING R 

3 PLAY AREA 

4 RECEPTION 
G CASHIER 

6 PHYSICIAN OFFICE 

T MEDICAL RECORDS 

8 STAFF WORK 

9 TECH WORK 

10 XRAY 




BREAST DIAGNOSTIC KEY: 



5 STAFF WORK 

6 MANAGERS OFFICE 
J EDUCATION 

a ULTRASOUND 

9 BONE DENT 1ST f 

10 CONSULTATION 

11 FILM PROCESSING 
1! VIEWING 

13 FtLM FILES 

14 LOUNGE 

15 CONFERENCE 

16 LAB 

17 ADMINISTRATION 

18 STORAGE 

19 WAITING ROOM 



TORRANCE BREAST DIAGNOSTIC AND FAMILY CENTER 

31574 SO. FT. FLOOR PLAN 



Figure 6-6. Space plan, Torrance Breast Diagnostic and 
Family Center, 31 ,574 square feet. (Architecture and interior 
design: Boulder Associates, Inc., Boulder, CO.) 



Primary-Care Clinics 319 



HEALTH MAINTENANCE ORGANIZATIONS 

In theory, any of these groups can be organized as a 
health maintenance organization although, since the 
obligation of an HMO is to provide a full range of health 
services to its members, it would most likely be only the 
large multispecialty group that would be prepared to do 
this. Kaiser is the best-known HMO of this type, referred 
to as a staff model because its providers are employees 
of the HMO. More commonly, HMOs contract with med- 
ical group practices, individual physicians, and other 
healthcare providers to provide services for their mem- 
bers who prepay a monthly fee, in addition to a fee or 
co-pay at the time the service is rendered. For many 
individuals, this arrangement centralizes and simplifies 
their healthcare and eliminates debates with insurance 
companies over what is covered and not covered, and it 
eliminates having to pay bills and write checks to a 
number of physicians. Members are issued an 
embossed identification card that is presented to the 
receptionist upon checking into the clinic. This saves 
time in heading up a form for each patient visit, and the 
identification card has the patient's billing code and 
other pertinent information on it. Increasingly, these 
transactions, patient identification, and records will be 
digital. Thus, although an HMO may have more sub- 
scribers than a similar-sized multispecialty group that 
charges a fee for service, billing procedures are often 
less complicated (there are no insurance claims to file) 
and are facilitated by sophisticated electronic data-pro- 
cessing and computer systems. 

Large multispecialty group HMOs like Kaiser have his- 
torically stressed health maintenance on the basis that it 
is less costly to keep people healthy than to treat them 
when they are sick. An HMO that follows this principle 
should be designed to accommodate many more patients 
than would a multispecialty group of the same number of 
physicians, and many more physician extenders will be 
employed in an HMO to provide health screening and 
other procedures aimed at preventive medicine. Having 
said that, it should be noted that the HMO of today differs 
from the somewhat idealistic model of yesteryear — one 



that promised to keep people healthy. Spending money to 
keep enrollees healthy only pays off if members stay with 
the plan a number of years. If they switch plans, the new 
HMO realizes the benefit. This has forced many HMOs to 
make tough decisions about how much they can offer at 
a capitated rate. Responding to inadequate government 
reimbursement, many HMOs pulled out of the Medicare 
program in January of 2001 , dropping over a million eld- 
erly and disabled individuals. The number of HMOs show- 
ing profitability dropped from 83 percent in 1993 to 41 
percent in 2000*. 

An HMO based on the staff or Kaiser model will usual- 
ly have a large physical therapy department, chemother- 
apy, cardiopulmonary lab, and allergy department — all of 
which may process a large volume of patients daily who 
do not have to see a doctor. 



HMO Models 

The three main types of HMOs are the independent prac- 
tice association (IPA), the combination model, and the 
network model. The IPA represents 58 percent of all 
HMOs, followed by combination models with 23 percent 
and network models with 12 percent. Staff and group 
models, together, total approximately 7 percent of the 
market^". In all but the staff model, the HMO contracts with 
medical groups or individual physicians to provide care to 
its enrollees and, in turn, contracts with employers to pro- 
vide services to their employees. In addition, HMOs enroll 
individual members and families. Following is a descrip- 
tion of the various HMO models. 

Independent Practice Association 

In this model, the HMO either develops or contracts with 
an existing association of individual physician practices to 
provide services to enrollees. Physicians are paid on a 
negotiated fee-for-service basis, or on a per capita basis, 
or a flat-fee retainer. IPAs allow physicians to remain in 



*lbid. 
"•"Ibid. 



320 Group Practice 



private practice and to treat subscribers in their own 
offices. Patients select from a list of providers, which 
includes hospitals, physicians, physical therapists, and 
others, to meet their healthcare needs. An HMO may 
employ a "gatekeeper" system that requires patients to 
select a primary-care physician who makes referrals to 
specialists, although some HMOs permit patients to self- 
refer to a specialist. 

Combination Model 

In this model, HMOs may combine two or more of the 
plan models. 

Network Model 

The HMO, in this model type, contracts with several mul- 
tispecialty group practices to provide services to 
enrollees residing in a single large service area or sever- 
al noncontiguous service areas with physicians common- 
ly reimbursed on a per capita basis. 

Group Model 

Consisting of one or more medical group practices, care 
is delivered in one central facility, supported by several 
satellite facilities. The group practice is paid on a nego- 
tiated per capita rate, and physicians receive a salary 
plus incentive payment. Patient care is usually managed 
by a primary-care physician who controls referrals to 
specialists. 

Staff Model 

In this model, physicians and other healthcare providers 
are full-time employees of the HMO and as such 
receive a salary. Care delivery is centralized in one or 
more locations, typically in large clinics. Care is man- 
aged by a primary-care physician who controls referrals 
to specialists. 



HMO Statistics 



health-planning regulatory agencies to ensure that they 
have met strict requirements with regard to their clinical 
services, quality management and improvement, utiliza- 
tion of personnel, and schedule of fees. As of January 
2000, there were 906 HMOs nationwide, with an enroll- 
ment of 104 million individuals.* However, consumer 
backlash against HMOs' stringent controls and restrict- 
ed choices has resulted in significant increases in 
enrollment in PPOs (Preferred Provider Organizations), 
which offer greater choice and give the consumer more 
control. 



POINT-OF-SERVICE (POS) 

In the late 1990s, an alternative to the HMO emerged, 
called the Point-of-Service plan. It has many similarities 
to HMOs in that it provides prepaid, comprehensive 
health coverage for both hospital and physician services 
and it requires members to select a primary-care physi- 
cian. The difference is that enrollees may select a 
provider outside the plan's network and receive coverage 
at a discounted rate. 



SINGLE-SPECIALTY GROUP 

This suite is composed of the same elements as a stan- 
dard medical office for a solo practitioner except on a 
larger scale. (The reader is referred to Chapter 3, 
Family Practice.) The functions of administration, patient 
care, and support services remain the same. It is the 
relationship of rooms that becomes critical as the suite 
becomes larger. It is no longer possible for all rooms to 
be close to each other as they are in a small suite. 
Administrative and support services may be centralized 
or decentralized — that is the major decision to be made 
at the outset. With a centralized plan (also known as an 
"island" plan), the business office, nurse station, lab, 



Health maintenance organizations are regulated by the 
state and are subject to close scrutiny by various 



*lbid. 



Single-Specialty Group 321 



Table 6-1. 

Analysis of Program. 

Group Practice — Single Specialty (Nonsurgical) 





Internal Medicine 


Family Practice 




8 Physicians 


8 Physicians 


Waiting Room(s) 




35 X35 


= 1225 a 




24 X 36 = 864 


Exam Rooms 


20® 


8X12 


= 1920 


24® 


8 X12 =2304 


Consultation Rooms 


8® 


12 x 12 


= 1152 


8® 


12 X12 =1152 


Nurse Stations 


3® 


10 x 12 


= 360 


3® 


10 X12 = 360 


Toilets 


4® 


7X8 


= 224 


4® 


7 X 8 = 224 


Storage 


2@ 


8X10 


= 160 


2® 


8X10 = 160 


Staff Lounge 




12 x 16 


= 192 




12 X16 = 192 


Laboratory* 




24 X 32 


= 768 




24 X 32 = 768 


Minor Surgery 




— 




2® 


12 X12 = 288 


Cast Room 




— 




Use Minor Surgery 


ECG/Treadmill 




12 X 12 


= 144 




12 X12 = 144 


Radiology 




12 X26 


= 312 




12 X12 = 312 


Flex Sig Room ' 




12 X 18 


= 216 




— 


Pulmonary Function 












Testing (Optional) 




14 X 16 


= 224 




— 


Business Office e 




24 X 24 


= 576 




24 X 24 = 576 


Office Manager 




10 X 12 


= 120 




10 X12 = 120 


Medical Records 




12 X 16 


= 192 




12 X16 = 192 


Insurance/Collections 




14 X 16 


= 224 




14 X16 = 224 


Subtotal 






8009 ft 2 




7880 ft 2 


25% Circulation' 






2002 




1970 


Total 






10,011ft 2 




9,850 ft 2 



"Includes calculation of late factor; see Chapter 3. Internal medicine physicians are often called to the ER 

or must visit hospitalized patients, which can account for delays. 

Includes lab waiting, blood draw, and toilet. This assumes lab work done in house. 

Includes darkroom, control, film filing, film viewing, and dressing area. (Radiography room not equipped 

for fluoroscopy.) 

includes prep area and toilet. 

"Includes reception, bookkeeper's office, transcription, and workroom. 

'Allows for 5- to 6-foot-wide corridors. 




£ErNTR/\UZ£D PLAN 
6lN6>L£r SPECIALTY 6R0UP 



Figure 6-9. Schematic diagram of a centralized plan for a single-spe- 
cialty group. 



and supply room would be grouped together, forming 
the core of the suite, with patient areas (exam and treat- 
ment rooms, consultation and waiting rooms) grouped 
around the perimeter of the core (Figures 6-9 and 6- 
10). 

The suite in Figure 6-10 enables seven providers (six 
physicians and a nurse practitioner) to see patients simul- 
taneously, each having three exam rooms. It is assumed 
that two of the eight physicians on any given day will 
either have a day off or be in surgery off site. In this high- 
volume specialty, the plan provides separate paths for 
patients entering and exiting the suite. 

With a decentralized plan, administrative and support 
services would be divided into units, each serving a cer- 
tain number of exam and treatment rooms. Exam and 
treatment rooms would be grouped into pods (three to six 
exam rooms to a pod) with an adjacent nurse station/lab 



322 Group Practice 



TO STAIR 



CONSULT 



CONSULT 



EXAM 



EXAM 



EXAM 



EXAM 



CONSULT 



CONSULT 




CONSULT 



CONSULT 



lEXAM 



lEXAM 



iEXAM 



?EXAM 



CONSULT 



EXAM 



EXAM 



EXAM 



CONSULT 



SINGLE SPECIALTY GROUP - OB/GYN 
CENTRALIZED PLAN 

8160 SF 



Figure 6-10. Space plan for single-specialty group (OB/GYN) accommodates eight physicians 
and one nurse practitioner, 8160 square feet. {Design: Jain Malkin Inc.) 



Single-Specialty Group 323 



Table 6-2. 

Analysis of Program. 

Group Practice — Single Specialty (Surgical) 







OB-GYN 




Orthopedics 






8 Physicians 


8 Physicians 




Waiting Room(s) a 




26 x 30 


= 780 




20 X 22 = 


440 


Exam Rooms 


19® 


8X12 


= 1824 


12 ft @ 


8 X12 = 


1152 


Exam/Ultrasound 


2@ 


10 x 12 


= 240 




— 




Consultation Rooms 


8@ 


12 X 12 


= 1152 


8@ 


12x12 = 


1152 


Nurse Stations 


3@ 


8X10 


= 240 


3 e @ 


8 X10 = 


240 


Toilets 


6@ 


7X8 


= 336 


4@ 


7X8 = 


224 


Storage 


2@ 


8X10 


= 160 


2@ 


8 X10 = 


160 


Staff Lounge 




12 x 16 


= 192 




12 X16 = 


192 


Lab 




12 x 16 


= 192 




12 X14 = 


168 


Minor Surgery 




14 x 16 


= 224 




12 X14 = 


168 


Cast Rooms 




— 




2@ 


12 X12 = 


288 


Radiology'' 




— 






12 X34 = 


408 


Business Office" 




16 x 30 


= 480 




16 X30 = 


480 


Surgery Scheduling 




10 x 10 


= 100 




10 X10 = 


100 


Office Manager 




10 x 12 


= 120 




10 X12 = 


120 


Insurance/Collections 




14 x 16 


= 224 




14 X16 = 


224 


Medical Records 




12 x 16 


= 192 




12 X16 = 


192 


Nurse Practitioner Office 




10 x 10 


= 100 




— 




Physical Therapy (Optional) 




— 






20 X 30 = 


600 


Subtotal 






6556 ft 2 






6308 ft 2 


25% Circulation' 






1639 






1577 


Total 






8195 ft 2 






7885 ft 2 



"Includes children's play area. 

''Assumes no more than four physicians seeing patients in the office at one time. 

Tech workstations. 

includes darkroom, control, film filing, and film viewing. 

"Includes reception, bookkeeping, transcription, and workroom. 

'Allows for 5- to 6-foot-wide corridors. 



and one or two consultation rooms (Figures 3-2, 6-11, 
and 6-12). It would be impractical to have more than one 
business office, medical records area, or insurance office, 
so these services would have to be located so that a 
patient exiting from any pod of exam rooms would follow 
a path leading him or her past the cashier's desk and 
appointment desk and back into the central waiting room. 
In a large clinic, proper circulation must be reinforced by 
strategically placed, easy-to-read signage (Figures 6-13 
and 6-15) and even unique destination entries (Color 
Plate 6, Figure 3-97). Inset carpet designs can be effec- 
tive as wayfinding cues (Figure 6-14). 




±\HOVer SPECIALTY G>R<PUP 

Figure 6-11. Schematic diagram of a decentralized plan for a sin- 
gle-specialty group. 



324 Group Practice 



ios'-o" 




EXAM 



EXAM 



TyLT\LPlLJ\l2 



EXAM 



Sg 



N.S./WTG. 



noonnooL^ 



i5F=- dooo oon 




□| 




NURSE V 
PRACT. ^-" 




S"T 




!■=■ 


X 


EXAM 


(" 


X 

D 















SINGLE SPECIALTY GROUP - DERMATOLOGY -DECENTRALIZED PLAN 

4752 SF 

Figure 6-12. Space plan for single-specialty group (dermatology), 4752 square feet, accommodates four providers: three physicians and one nurse prac- 
titioner. (Design: Jain Malkin Inc.) 



Single-Specialty Group 325 




Figure 6-13. Clinic signage system: 
Each medical specialty has a color 
identification. {Design: Jain Malkin Inc.; 
Photographer: Jain Malkin.) 




Figure 6-15. Modular signage panel alongside doors is both functional 
and attractive. Frisbie Memorial Hospital, Rochester, NH. (Photo courtesy: 
TRO/The Ritchie Organization, Newton, MA; Photographer: Edward 
Jacoby Photography.) 



Figure 6-14. Corridor intersection with good wayfinding cues. Saint 
Francis Hospital, Hartford, CT. [Photo courtesy: TRO/The Ritchie 
Organization, Newton, MA; Photographer: Warren Jagger.) 



326 Group Practice 



MULTISPECIALTY GROUP 

This type of clinic offers the greatest challenge to a 
designer. The space to be planned may be vast, and each 
specialty must be carefully analyzed for its relationship to 
other specialties (Figures 6-16 and 6-17). Large multi- 
specialty clinics tend to grow and change a good deal. 
Physicians leave, and others join the group. Departments 
are sometimes shuffled around to realign them according 
to new priorities. The facility should be designed for 



expansion with anticipation of which departments may 
outgrow their present limits. 

Radiology, for example, tends to expand. New equip- 
ment is introduced, and due to the scale of the machin- 
ery, a single piece may require its own room. Thus, it is a 
good idea to locate the radiology department on the 
perimeter of the suite adjacent to the area allocated for 
expansion. Radiography rooms are very costly to build 
due to special electrical, plumbing, and lead-shielding 
requirements; therefore, it would not be economically fea- 




0.P 




£NT 




INT. 














1SAD. 


ENTRY 


ADMlN 












WAIT. 




my=> 


AUfcRtff 



Figure 6-16. Schematic diagram of a satellite plan for a multispecialty group. 



MULTI-Sre£\ALTY 6R0VP 



Figure 6-17. Schematic diagram of a multispecialty 
group, showing the relationship of specialties for opti- 
mum function — keeping the highest volume toward 
the front, pediatrics close to allergy, radiology close 
to internal medicine, lab and business office central 
to all. 



Multispecialty Group 327 



Table 6-3. 

Analysis of Program. 

Group Practice — Multispecialty — 9 Physicians 

This program assumes the following: two internists, three family practitioners, three pediatri- 
cians, and one otolaryngologist; a central business office and lab will serve all; in addition to 
the central supply, several small storage rooms would be scattered throughout the facility. 

Waiting Room(s) 

Children's Play Area 

Peds Sick and Well Waiting 
Pedo Exam Rooms 2@ 8x12 & 

Pedo Nurse Station 
Pedo Consultation Rooms 
Pedo Minor Surgery 
ENT Exams 
Audio Room 
ENT Minor Surgery 
ENT Consultation Room 
ENT Nurse Station 
IM Exam Rooms 
IM Consultation Rooms 
IM Nurse Station 
Flex Sig Room a 
ECG/Cardiopulmonary Lab 
Family Practice Exam Rooms 
Family Practice Consultation Rooms 
Family Practice Nurse Station 
Cast Room 

Minor Surgery/Procedures 
Staff Lounge 
Central Supply 
Medical Records 
Administrator 
Lab 6 

Radiology" 1 
Toilets 
Business Office 

Reception 

Bookkeeping 

Insurance/Collections 

Transcription 

Workroom 

Subtotal 

25% Circulation 1 * 

Total 

"Includes prep area and toilet. 

includes lab, lab waiting, blood draw, toilet, and storage. This assumes lab work done in house. 

includes darkroom, control, film filing, viewing areas, and dressing area. 

d Allows for 5- to 6-foot-wide corridors. 





24 X 30 = 


720 
120 
600 


8@ 


8X 10 = 


832 




10 x 12 = 


120 




10 x 12 = 


360 




12 X 12 = 


144 


3@ 


8 X 12 = 


288 




10 X 12 = 


120 




12 X 12 = 


144 




12 X 12 = 


144 




8 X 10 = 


80 


6@ 


8 X 12 = 


576 


2@ 


12 X 12 = 


288 




8 X 10 = 


80 




12 X 18 = 


216 




16 X 20 = 


320 


9@ 


8 X 12 = 


864 


3@ 


12 X 12 = 


432 


2@ 


8 X 10 = 


160 




Use Minor Surgery 




12 x 12 = 


144 




16 x 18 = 


288 




12 x 16 = 


192 




16 x 18 = 


288 




10 x 12 = 


120 




24 x 32 = 


768 




12 x 26 = 


312 


7@ 


7X8 = 


392 




12 X 14 = 


168 




16 X 20 = 


320 




16 x 20 = 


320 




10 X 12 = 


120 




10 x 10 = 


100 
10,140 ft 2 
2,535 
12,675 ft 2 



sible to abandon existing radiology rooms, tearing them 
down to remodel for less specialized use such as addi- 
tional examination rooms or an expanded waiting room. 
By locating the radiology department contiguous to the 
area of the proposed future expansion, existing radiology 
rooms need not be altered and new rooms could be 
added. 

Medical records is another area that often has to be 
expanded. However, since this would typically be located 
in the core of the suite, it is usually difficult to enlarge it. It 
is better to project a realistic number of charts and growth 
for a seven-year period (physicians generally keep med- 
ical records for seven years) and make the room large 
enough to begin with. 

If the building is designed for and owned by the doc- 
tors, the architect can take liberties with the design and 
make the structure of the building really conform to the 
spatial requirements of the group's practice. A large clin- 
ic may be laid out with the administrative and support 
services in the core, with each specialty department radi- 
ating out from it like spokes of a wheel. Each "spoke" 
would have its own nurse station and waiting room, but 
the clinical lab, medical records, insurance, business 
office, and so on would be in the core area (Figure 6-18). 
This is also known as a satellite plan. 

If the square footage of each specialty department is 
not great, one large waiting room may be designed near 
the reception and business office. Patients would be 
called from there to the various departments. More 
often, each specialty department would function inde- 
pendently with its own waiting room, reception desk, 
nurse station, and other support facilities. There may be 
a central reception desk and waiting room at the 
entrance of the clinic, where an aide may prepare a form 
that the patient carries to the sub-reception desk located 
at the specialty department. Upon checking out, the 
patient may book a future appointment either at the sub- 
reception desk or at the central reception desk, depend- 
ing on how the flow is set up. Payment for services 
would usually be made at the central reception desk or 
cashier's counter, if one exists, rather than at the spe- 
cialty department. 



328 Group Practice 



The multispecialty group-practice clinic shown in 
Figures 6-1 9a, b, c is 30,000 square feet in size and locat- 
ed on 2 1 / 2 floors of a large medical office building. The clin- 
ic includes internal medicine, family practice, radiology, 
pharmacy, vascular lab, cardiopulmonary testing, clinical 
lab, and a large endoscopy suite. Medical records, con- 
ference room/staff lounge, and the clinic administrator's 
office are on the lower level. Medical charts are brought 
up from the lower level to the circulation point on each 
floor via a dumbwaiter. 

The clinic functions as a group-practice model HMO, 
a preferred provider organization (PPO), and also 
accepts fee-for-service patients. On the first visit, the 
patient registers on the first floor, near the family prac- 
tice reception desk, where an embossed card is dis- 
pensed, paperwork is handled, and a medical chart is 
prepared. The patient is then referred to the appropriate 
decentralized reception desk to check in prior to receiv- 
ing treatment. On subsequent visits, the patient pro- 
ceeds directly to the reception desk at the respective 
department and does not need to stop at the registra- 
tion desk. 

This is an example of a decentralized plan where each 
specialty department has its own reception and waiting 
area, with nurse stations, exam rooms, and private offices 
arranged in pods. 

Great attention was paid to circulation patterns in order 
to minimize the possibility of patients leaving without 
passing the cashier's desk. On the first floor, inset carpet 
designs and unique signage properly placed lead 
patients past the principal cashier station, while radiology 
patients exit through the radiology waiting room. On the 
second floor, all exiting circulation is directed past two 
cashier stations. 



ORTHOPEDICS 



OTOLARYNGOLOGY 




PEDIATRICS 



Figure 6-18. Space plan for mixed-specialty group, satellite plan, 14,337 
square feet. (Design: Jain Malkin Inc.) 



INTERNAL MEDICINE GROUP 

This is a single-specialty group, but due to the many 
internal medicine subspecialties, more specialized 
rooms and a larger clinical lab and radiology suite are 
required than with most single-specialty groups. 



Internal Medicine Group 329 




MULTI-SPECIALTY GROUP PRACTICE CLINIC, 30,000 SF 
MAIN LEVEL FLOOR PLAN 



Figure 6-1 9a, b, and c. Space plan for multispecialty group, 30,000 square feet. (Design: Jain Malkin Inc.) 



330 Group Practice 





MULTI-SPECIALTY GROUP PRACTICE CUNIC 
SECOND LEVEL FLOOR PLAN 



MULTI-SPECIALTY GROUP PRACTICE CUNIC 
LOWER LEVEL FLOOR PLAN 



Figure 6-19b. 



Figure 6-19c. 



Internal Medicine Group 331 



An internist specializing in cardiology or in pulmonary 
disease would need an ECG room and a cardiopul- 
monary lab. One who specializes in gastroenterology 
would require a sigmoidoscopy room and perhaps an 
endoscopy suite. Endocrinologists, on the other hand, 
order many lab studies — some of which require patients 
to report to the lab in the morning and remain nearby for 
four to six hours, with blood being drawn every hour. 
Thus, the lab must be of sufficient size to accommodate 
a high volume of work and should have a comfortable 
lounge for waiting patients. 

The suite for a group practice of internists would typi- 
cally have three exam rooms for each doctor, a consul- 
tation room for each physician adjacent to his or her pod 
of exam rooms, a toilet, and a nurse station. The flex sig 
room, ECG treadmill, cardiopulmonary lab, clinical lab, 
and radiology suite would be located in the core area 
central to all exam rooms. The business office, insurance 
office, cashier's desk, and waiting room would be locat- 
ed at the entrance to the suite so that each patient, upon 
entering and leaving, must pass by the reception and 
cashier's desks (Figure 6-20). 

A large group practice will have a business manager or 
an administrator who will require a small private office 
preferably with a window wall (starting at 48 inches off the 
floor) facing the business office so that he or she can 
keep an eye on operations at all times. 

Patients may at times report to the lab without having 
to see a physician, so the lab should be located at the 
front of the suite, enabling a patient to enter and leave 
without mingling with patients waiting for visits with a 
physician. In fact, there might be an entrance from the 
street (or public corridor of the medical building) directly 
into the lab. The reader is referred to Chapter 5 for space- 
planning requirements of a clinical lab. 

The waiting room must accommodate one hour's 
patients per doctor. Thus, if each doctor can see an 
average of four patients per hour and each has three 
examining rooms, an eight-physician group would need 
seating for approximately 40 persons in the waiting 
room or elsewhere within the suite when all doctors are 



seeing patients simultaneously. A formula for estimating 
the required number of seats is 

2P x D - E = S 
where 

P = Average number of patients per hour per 
physician 

D = Number of doctors 

E = Number of exam rooms 

S = Seating 

The formula assumes that each patient arrives with one 
other person, a friend or relative. 

Allowing that some patients will arrive unaccompanied 
by a friend and some will be directed to the lab, X-ray, 
procto room, or ECG room, the 40 required seats might 
be reduced to 35 at the absolute minimum. Figuring 18 
square feet per person, a waiting room that will accom- 
modate 40 persons will have to be approximately 800 
square feet in size, allowing extra space for wheelchairs. 
Include additional space for a children's play area. 

FAMILY PRACTICE GROUP 

The suite for a family practice group would be an expansion 
of a suite for a solo practioner (refer to Chapter 3). It would 
also include an X-ray facility, lab, private office for a busi- 
ness manager, and maybe a small allergy suite. Often, a 
group of family practitioners includes a general surgeon. 
The formula discussed above for estimating the number of 
seats in the waiting room applies here, except that a family 
practitioner can see up to six patients an hour, and each 
physician should have the use of three exam rooms. 



Note: Medical Group Management Association (Englewood, Colorado), known as 
MGMA, is the oldest and largest member organization for group practices, found- 
ed in 1926. According to a January 2001 news release, MGMA represents 6000 
healthcare organizations and 176,000 practicing physicians. It is an excellent 
resource for a variety of statistics and information. SMG Marketing Group 
(Chicago, Illinois) is another good source of statistics and forecasts published in a 
newsletter format. 



332 Group Practice 



INTERNAL MEDICINE 




GROUP PRACTICE 
CENTRALIZED PLAN: 
INTERNAL MEDICINE & 
GENERAL PRACTICE 



12,584 SF 



GENERAL PRACTICE 



Figure 6-20. Space plan for group practice of 14 physicians, centralized plan, 12,584 square feet. {Design: Jain Malkin Inc.) 



Family Practice Group 333 



CHAPTER 7 



Ambulatory Surgical Centers 



OVERVIEW 

Ambulatory surgery refers to scheduled surgical proce- 
dures provided to patients who do not require overnight 
hospitalization. Ambulatory surgery may be provided in a 
physician's office — in which case it is called office-based 
surgery — or in a freestanding, independent facility specifi- 
cally organized to provide scheduled ambulatory surgery. 
In this chapter, the acronyms FOSC (freestanding outpa- 
tient surgery center) and ASC (ambulatory surgical center) 
are used interchangeably. 

The practice of ambulatory surgery is not a new con- 
cept. The British Medical Association in 1909 reported 
7320 operations performed by a Scottish physician on 
ambulatory patients at the Royal Glasgow Hospital for 
Children.* The results were reported to be as successful 
as those for inpatient surgery. However, the interest in 
ambulatory surgery declined somewhat until the early 
1 960s when the development of new fast-acting anesthet- 
ics made ambulatory surgery more practical. 

The first successful freestanding ambulatory surgical 
center is generally recognized to be the Phoenix 
Surgicenter®, which began operations in February 1970. 
Anesthesiologists Wallace Reed and John Ford estab- 
lished the facility that has become the model for other non- 
hospital-based ambulatory surgical centers. 

The freestanding ambulatory surgical center may be 
organized according to a variety of operational models that 
vary according to type of ownership and sponsorship, affilia- 
tion with hospitals, and types of services offered. The term 



•Thomas O'Donovan, Ambulatory Surgical Centers, Aspen Systems Corp., 
Germantown, MD, 1976, p. 4. 



freestanding may be used to refer to a facility that is physi- 
cally separate from another, such as a hospital, or it may 
mean a facility whose program and ownership are inde- 
pendent and legally distinct from any other organization. 

Ambulatory surgical centers may be located within a hos- 
pital, may be a separate building located on the hospital 
campus, or may be a satellite facility located off campus. 
Some ambulatory surgical centers are entrepreneurial 
enterprises owned and operated by a group of anesthesiol- 
ogists or surgeons and have no affiliation with a hospital. 
These facilities are commonly located within a medical 
office building, or they may be physically freestanding in a 
single-tenant building. It is this last example that is the focus 
of this chapter — a facility not owned by a hospital and locat- 
ed in a medical office building, or freestanding. 



ADVANTAGES OF AMBULATORY SURGERY 

There are many advantages to ambulatory surgery from 
both the patients' and the physicians' viewpoints. Some of 
these advantages follow. 

1 . Hospitals are geared to traditional inpatient surgery pro- 
tocols, which are often inappropriate for ambulatory 
patients, whereas a facility organized for the sole pur- 
pose of ambulatory surgery would have a staff trained to 
meet the specific needs of these patients. Hospitals 
sometimes find it difficult to merge new protocols with 
existing systems. 

2. Ambulatory surgery patients are not sick; they are candi- 
dates for elective procedures. In a hospital, their families 
may have to share a common surgery waiting room with 



334 



inpatients' families, which can have a devastating psy- 
chological effect. Imagine the stress of sitting next to 
someone whose husband may be having open heart 
surgery. 

3. Patients often experience psychological stress when 
entering a hospital. Fear of the unknown is height- 
ened by unexpected sights, such as a view of a 
patient arriving in an ambulance or seeing a patient 
on a gurney with an IV in the arm. Patients are gen- 
erally less apprehensive when arriving for surgery in 
a facility located in a medical office building. 

4. Physicians and staff often experience greater satisfac- 
tion in an FOSC because they can tailor operational 
systems as they wish, with no bureaucratic red tape. 

5. There is much greater flexibility in scheduling proce- 
dures in an FOSC. In a hospital, ambulatory patients 
will be bumped to open up the schedule for urgent or 
emergent patients. Both physicians and patients find 
ease of scheduling an advantage in an FOSC. 

6. Ambulatory surgery provides better utilization of hos- 
pital beds and costs considerably less than doing the 
same procedure in a hospital. The major savings is due 
to elimination of a hospital stay, and insurance payers 
often stipulate they will pay for certain procedures only 
if done within an ambulatory surgical center. 

7. Ambulatory surgical patients receive less medication 
both pre- and postoperatively, and they often return to 
work sooner than people who have those same pro- 
cedures as inpatients. Perhaps this is due to the fact 
that FOSCs promote a wellness philosophy, treating 
patients as if they are healthy, and allowing them to 
take responsibility for a large part of their own care. 



OWNERSHIP AND AFFILIATION 

A great many mergers and acquisitions in 1999 resulted 
in 69.6 percent of FOSCs being independently-owned, 27 
percent owned by multifacility chains, and 3.4 percent 



hospital owned. HealthSouth of Birmingham, Alabama, is 
the nation's largest FOSC multifacility chain, owning 8 
percent of the total market with 229 facilities. 
Columbia/HCA Healthcare Corp. is the second largest 
chain with 123 facilities.* If the HCFA ambulatory pay- 
ment classification (APC) system reimbursement rates 
are more favorable to hospital-based outpatient facilities, 
this may tip the scale in that direction. 



ECONOMIC AND REGULATORY ISSUES 

Prior to designing an FOSC, it is necessary to understand 
the facility's goals with respect to licensing, certificate-of- 
need (CON) requirements, accreditation, and reimburse- 
ment by Medicare/Medicaid and commercial insurance 
carriers. 

Ambulatory surgery centers (ASCs) are highly regulat- 
ed at the federal, state, and peer level. Most facilities will 
be state licensed, have Medicare certification, and 
JCAHO or AAAHC accreditation. AAAHC has been grant- 
ed "deemed status" by HCFA (Health Care Financing 
Administration) to certify ASCs for Medicare participation 
as can JCAHO. 

The American Association of Oral and Maxillofacial 
Surgeons (Web site aaoms.org) offers a state-by-state 
summary of requirements for licensure and Medicare cer- 
tification for operation of ambulatory surgical centers. 



Licensure 

A facility owned and operated by a physician group prac- 
tice generally need not be state licensed, provided that 
non-owner surgeons are not allowed privileges. However, 
the state business and professions Code in some states, 
such as California, does require even solo practitioners to 
obtain licensure, certification, or accreditation if they 
administer general anesthesia "in doses that place 

*SMG Marketing Group Inc. FOSCs Database, June 1999 edition. 



Economic and Regulatory Issues 335 



patients at risk for loss of life-preserving protective reflex- 
es." In other states, a physician's license to practice his or 
her specialty may meet the requirements. Surgical proce- 
dures are usually done on a small scale and are performed 
within the context of the physician's practice. State agen- 
cies often do not regulate office-based surgery, although 
there is increasing pressure for greater regulation. The 
American Society for Aesthetic Plastic Surgery, for exam- 
ple, mandated that, by January 1 , 2002, practitioners must 
be accredited by one of the national organizations such as 
AAAASF (American Association for Accreditation of 
Ambulatory Surgery Facilities), which accredits all surgical 
specialties. Office-based surgery facilities are discussed in 
greater detail in Chapter 4 under Plastic Surgery. 

When a facility is organized specifically for the purpose 
of ambulatory surgery, and a surgeon need not be an 
owner to be awarded privileges, then licensure of the 
facility is an issue. Licensing is often a requirement for 
receiving state reimbursement, and insurance payers 
may require that a facility be licensed for their participa- 
tion. Furthermore, licensed facilities may be eligible for 
rate discounts from liability carriers. 

NFPA 101 Life Safety Code and state building codes 
are the standard for all licensing and certification require- 
ments. The designer must check with the state fire mar- 
shal, state facilities' development agencies, the local 
building department, and the local department of health 
services to ensure that all requirements are identified. 
The cost of designing a facility initially to meet licensing 
requirements will be comparatively small compared with 
trying to retrofit it later to achieve compliance. Licensing 
offers a certain amount of economic security in that it 
assures the facility of receiving the maximum amount of 
reimbursement offered by payers. Currently, 41 states 
require state licensure of ASCs, making them the most 
highly regulated type of ambulatory medical facility. 



CON/Health Systems Agency Review 

Each state is unique in its approach to regulating FOSCs. 
The Health Planning and Resources Development Act of 



1974 mandated that state governments establish 
Certificate-of-Need (CON) programs to regulate health- 
care facilities and services. In some states, a CON may 
be required for an FOSC, whether it be owned by a hos- 
pital or another entity. The purposes of the CON are to 
prevent duplication of highly specialized facilities and 
equipment and to keep a lid on rising healthcare costs. 
Some states exempt facilities from the CON process if 
they are not owned by a hospital. 

In many states, the CON process starts with a review 
by the local health systems agency (HSA), which must 
endorse the project and make recommendations to the 
state. Early in the planning stages of an FOSC, it is 
essential to ascertain whether a CON may be required 
and whether HSA endorsement is mandatory. If a local 
HSA does not exist, there may be another areawide 
health planning agency that should be consulted. It 
should be noted that many states have abandoned their 
CON programs since the federal government ceased 
funding them. The national trend toward deregulation 
allows FOSCs a much easier path to their goals. 
Currently, 36 states have some type of CON regulations. 



Accreditation 

The Joint Commission of Accreditation of Healthcare 
Organizations (JCAHO) can accredit freestanding 
ambulatory surgical centers that are not owned by hos- 
pitals; however, accreditation by the Accreditation 
Association for Ambulatory Health Care (AAAHC), 
established in 1979 (located in Wilmette, Illinois), is 
more common. This is a voluntary accreditation pro- 
gram aimed at quality assurance in all aspects of 
patient care. The agency publishes a handbook of stan- 
dards for ambulatory healthcare as well as a code 
checklist for ambulatory surgical facilities based on 
compliance with NFPA 101 Life Safety Code. In sum- 
mary, accreditation is a voluntary assessment process 
whereby industry experts and peers define conformity 
standards by which surveyors evaluate and rate the 
organization's performance. It's a means of identifying 



336 Ambulatory Surgical Centers 



and validating for the consumer quality facilities that 
meet recognized standards. 

It should be noted that there is a national nonprofit 
association for freestanding ambulatory surgical centers 
called FASA (Federated Ambulatory Surgery 
Association), with national headquarters located in 
Alexandria, Virginia. FASA publishes a bimonthly journal 
and an annual bibliography on ambulatory surgery issues 
with the goal of improving the delivery of outpatient sur- 
gery. FASA helped organize the AAAHC. 



Certification 



fessional fees, and the other is the facility fee — the 
charge for the surgical suite, operating room staff, and 
supplies. Third-party payers vary in their reimbursement 
policies with respect to these two components. 

Physicians are generally reimbursed a "reasonable and 
customary" fee for their services regardless of whether 
the facility is licensed or certified; however, third-party 
payers will not pay for the use of the facility unless it 
meets certain criteria. These usually involve a strict 
adherence to the Life Safety Code. Therefore, Medicare 
certification and/or state licensure assure that the FOSC 
will be reimbursed for the use of the facility. 



Medicare certification is a requirement for receipt of feder- 
al reimbursement for patients eligible to receive these ben- 
efits. Medicare and Medicaid are programs administered 
by HCFA. With respect to the physical plant, Medicare 
does not stipulate sizes of rooms or number of scrub sinks 
per operating room, but rather relies entirely on compli- 
ance with NFPA 101 Life Safety Code. Medicare engages 
a local state fire marshal to conduct the survey of a new 
facility to verify compliance. Medicare certification paves 
the way for approval by other reimbursement agencies and 
insurance payers. It constitutes the seal of approval, so to 
speak. In reality, there is little difference between licensure 
and certification with respect to design criteria, because 
both rely on compliance with the Life Safety Code. Ninety 
percent of ASCs are Medicare certified. 

HCFA Definition of ASC 

HCFA defines an ASC as "any distinct entity that operates 
exclusively for the purpose of providing surgical services 
to patients not requiring hospitalization."* 



Reimbursement Policies 

The total charge for a surgical procedure has two com- 
ponents. One is the anesthesiologist's and surgeon's pro- 

*Title 42, Vol. 2., Sec. 416.2 Code of Federal Regulations, revised Oct. 1, 1999. 



MARKETING CONSIDERATIONS 

An appealing aspect of surgery in a freestanding facility 
is the element of choice. A physician may have privileges 
at several facilities and may offer the patient the opportu- 
nity to choose the preferred setting. Along with that 
choice comes the expectation of convenience and care 
delivered in a small-scale, noninstitutional, friendly envi- 
ronment. Patient satisfaction is necessary for a facility's 
success, and many ASCs are keenly aware of guest rela- 
tions. Both patients and physicians benefit from the fact 
that, according to a study by Arthur Andersen, more than 
82 percent of cases start on time in ASCs. 

The interior environment is a critical element of 
patient satisfaction. The entire facility should use color 
to relax and soothe patients, and texture may be intro- 
duced in carpets and wallcoverings, whenever appropri- 
ate (in terms of maintenance and infection control). 
Artwork and accessories should not be overlooked as a 
means of distracting patients and making the facility 
less threatening. 

However, patients and their families are not the only 
ones who benefit from a well-designed environment. To 
attract top-quality physicians and nursing staff and to 
keep morale high, staff areas must be properly designed 
so that they are functional and they should look as attrac- 
tive as patient areas. 



Marketing Considerations 337 



SURVEY OF SURGICAL PROCEDURES 

Advancements in medical technology such as lasers and 
endoscopic surgery enable an increasing number of pro- 
cedures to be carried out in a minimally invasive manner, 
safely, in an outpatient facility. According to FASA, over 50 
percent of all surgery is performed in an outpatient setting 
at lower cost, greater convenience, and quality that meets 
or exceeds that of hospital-based surgical facilities. 

It is helpful to understand, prior to designing a facility, 
the types of procedures that are normally performed in an 
FOSC. A survey of facilities nationwide is represented in 
Table 7-1, indicating that 66 percent of procedures fall 
into four specialty categories. 



HCFA-Covered Procedures 

Covered surgical procedures defined by HCFA are those 
that can be safely performed in an ASC; are not com- 
monly or safely performed in physicians' offices; require a 
dedicated operating room and post-op recovery room 
(not overnight); can generally be executed in 90 minutes 
in the OR and do not exceed 4 hours' recovery time; do 
not result in extensive blood loss; do not require major or 
prolonged invasion of body cavities; do not directly 

Table 7-1 . 

Specialty Surgical Procedures Performed in 

Ambulatory Surgery Centers in 1998 



Type of Procedure 






Percentage 


Ophthalmology 








26.8 


Gastroenterology 








18.8 


Gynecological 








9.5 


Orthopedic 








9.8 


ENT 








6.9 


Plastic Surgery 








7.7 


Other (pain block, 


urology, podiatry, 


dental, 


neurology) 


20.5 
100% 



Source: ©1999 by the SMG Marketing Group, Inc. 



involve major blood vessels; and are generally not life- 
threatening or emergency in nature. In addition, general 
anesthesia must not exceed 90 minutes duration. 



TRENDS AND INNOVATION 

Advances in Pharmacology 

Pharmaceuticals have changed outpatient surgical prac- 
tices. These include new short-acting anesthesia agents 
that wear off in minutes, fast-acting agents for pain and 
postoperative nausea, and anesthetic agents that enable 
"fast-tracking" — bypassing the recovery room by trans- 
ferring the patient directly from the OR to the second- 
stage recovery area. Fast-tracking is expected to result 
in significant cost savings; however, it is appropriate pri- 
marily for patients who have had uncomplicated proce- 
dures and only if they meet physiological discharge cri- 
teria. The patient is actually awakened while still in the 
OR and allowed to recover there (which requires only a 
few minutes) prior to being moved to second-stage 
recovery. 



Minimally Invasive Surgery 

Surgery performed in ways not requiring large open inci- 
sions — for example, laparascopically — is revolutionizing 
outpatient surgery. There is less scarring, shorter recov- 
ery times, less disability, lower medical risks, better clini- 
cal outcomes, and reduced costs. Endoscopic surgery 
has become so popular that "videoscopy suites" are being 
developed across the nation. 



Harmonic Scalpel 

Using ultrasound technology, the Harmonic Scalpel® by 
Ethicon Endo-Surgery cuts tissue and seals blood ves- 
sels at the precise point of impact, resulting in minimal lat- 
eral thermal tissue damage. Instead of burning the tissue, 



338 Ambulatory Surgical Centers 



the scalpel's vibration clots the blood to stop the bleeding. 
Lasers, on the other hand, operate at very high tempera- 
ture to vaporize or burn tissue. 



FACILITY DESIGN 

An enormous amount of careful planning precedes the 
establishment of an ambulatory surgical center. Feasibility 
studies analyze the demographics of the area and deter- 
mine the demand for such a facility. In terms of codes and 
regulatory agency review, an FOSC is certainly the most 
complicated of any outpatient facility. 



Location 

The feasibility study will identify, among other things, the 
geographical area from which patients will be drawn. 
Travel time factors heavily into the equation. FOSCs, after 
all, are designed to be convenient for patients and physi- 
cians; therefore, driving distance and site accessibility are 
important. Traffic patterns near the location, parking avail- 
ability, visibility from the street, and building appearance 
all require consideration. 

What makes an FOSC so sensitive to these factors is 
that the best marketing efforts cannot create an 
increased demand within a given area for surgical servic- 
es. Business must be generated from within the existing 
demand of the area served. Marketing studies will reveal 
whether there is excess demand, whether existing facili- 
ties are underutilized, or whether projected growth will 
support the additional service. 



Transfer Agreement 

The preference for a facility to be located near a hospital 
is a matter of individual consideration. The incidence of 
need for patient transfer to a hospital following outpatient 
surgery has been much lower than was originally antici- 
pated. Those transfers that have occurred were nearly 



always for pain control or for persistent bleeding. Transfer 
for life-threatening conditions has been rare according to 
studies done by the FASA. This is the result of careful 
patient screening to determine potential risks and careful 
selection of types of procedures. Nevertheless, a transfer 
agreement with a local hospital is required. 



Codes 

The FOSC has many characteristics of a hospital inpa- 
tient surgery unit and must comply with many, but not 
necessarily all, of the same requirements imposed upon 
hospitals. To receive certification and/or licensure, state 
administrative codes and NFPA 101 Life Safety Code 
must be followed. Federal guidelines focus almost entire- 
ly on operational policies and procedures of the facility, 
and they make no demands above state requirements for 
the built environment. 

Explosion/Fire/Electrical Shock. Codes are designed 
to prevent a variety of hazards in the operating room and 
recovery areas and to reduce fire hazards elsewhere. The 
National Electrical Code (NEC) is widely used across the 
nation to set standards for the use of electricity. This code, 
like the others described here, is implemented through 
adoption by state and local jurisdictions, and exact 
requirements vary somewhat from region to region. For 
instance, explosive anesthetic gases, which might be 
ignited by a stray spark, are no longer in use, yet some 
states require that conductive flooring and isolated elec- 
trical power be used. Other states recognize that this is 
unnecessary. 

NFPA 101 concentrates on fire protection and preven- 
tion. NFPA 99 is the industry standard for storage and dis- 
tribution of hazardous gases, vacuum systems, essential 
electrical systems, and respiratory therapy. 

Power Failure. Emergency power for certain medical 
equipment and for egress lighting is required. The capac- 
ity and intended use are described in the NEC, Section 
517. It gives requirements for ORs and recovery areas 



Facility Design 339 



and defines which features are required to enhance life 
safety. 

Infection Control. The most pervasive risk in the surgery 
setting is that of infection. This involves two issues: con- 
tamination of the open wound and staff exposure to HIV or 
hepatitis virus. Facility design, internal protocols for han- 
dling infectious waste, and proper protection during sur- 
gery are the three principal ways of reducing this hazard. 

Patient and staff circulation patterns bear significantly 
on the spread of infectious microorganisms. This often 
poses a challenge for the space planner, since program 
requirements often exceed available space, sometimes 
reducing circulation alternatives. State building codes 
usually establish standards for smooth and washable fin- 
ishes and for special ventilation requirements within spe- 
cific areas, but there is little of a definitive nature in the 
way of regulatory codes to assist the designer in laying 
out the suite to minimize the spread of infection. Common 
sense, experience, and guidance of the OR supervisor 
often dictate best practices. 

Today, the risk of acquired immune deficiency syn- 
drome (AIDS) and hepatitis B and C is the major health 
hazard to be encountered whenever working with blood 
or body fluids. Extreme care must be taken in the surgery 
setting to protect both patients and staff. The Centers for 
Disease Control in Atlanta and the Association of 
perioperative Registered Nurses (AORN) in Denver offer 
written guidelines on facility design and patient handling 
to control the risk of infection. 



OPERATIONAL PROTOCOLS 

FOSCs adhere to very strict procedural protocols. To 
assure life safety and quality of care, and to move 
patients and supplies through the facility with ease and 
efficiency, it is imperative that each task be performed 
routinely, in the same manner, by all personnel. The 
AAAHC guides facilities on protocols for medical record 
keeping, patient discharge procedures, quality assur- 
ance/peer review, patients' rights, and so forth. 



Every aspect of patient handling is based on a proto- 
col developed by the individual facility, to assure that 
nothing is forgotten or overlooked. While many of these 
protocols do not actually have an impact on the physical 
design of the facility, it is important for a successful proj- 
ect to include in the planning process representatives of 
all staff functions, including anesthesiologists, surgeons, 
nurses, and administrative staff. The space planner must 
avoid making any assumptions about a center's opera- 
tions that could inadvertently defeat operational effec- 
tiveness. 



PATIENT FLOW 

There are seven stages of patient flow through the facili- 
ty: preadmitting, arrival, patient prep, induction, recovery, 
postrecovery, and discharge. The patient's first encounter 
with the facility may be a day or two prior to surgery, to 
complete preadmission forms, undergo laboratory tests, 
and receive dietary instructions. Sometimes this is han- 
dled by phone and lab tests are not always necessary. 

This may be the first time the patient has ever had sur- 
gery, or perhaps the first time the patient has had ambu- 
latory surgery, and he or she may have no frame of refer- 
ence upon which to rely to combat fear and anxiety. 
Therefore, it is important that the preadmitting process 
give the patient confidence about the experience. After 
all, a patient truly cannot evaluate the quality of the clini- 
cal care or the surgeon's competence, but patients do 
make judgments nevertheless, based on interactions with 
staff and an assessment of the interior environment. 

A patient's confidence can be bolstered by an under- 
standing of exactly what to expect on the day of surgery. 
Nursing staff, anesthesiologists, and surgeons all play a 
significant role in educating and reassuring the patient. If 
the facility is designed well, circulation patterns will be 
predictable and convenient, allowing easy access for 
patients, staff, and family. Good design should make it 
easy for staff to do things right. 

The patient arrives on the day of surgery approxi- 
mately one and one-half hours prior to the scheduled 



340 Ambulatory Surgical Centers 



surgery time, accompanied by an escort. Some facilities, 
it should be noted, do the lab work on the day of surgery, 
which means patients may have to arrive a little earlier. 
The patient is next directed to a preparation area where 
street clothes are exchanged for surgical apparel. This 
may be handled in a number of ways. Some facilities 
have dressing rooms and lockers for storage of the 
patient's belongings (Figure 7-1), while others have the 
patient undress in a private prep/exam room (Figure 7- 
2), and belongings may be placed in a container that is 
stored in a secured area. In the recovery room, belong- 
ings are returned to the patient prior to dressing for dis- 
charge. In many states, regulators insist that patient 
belongings be stowed in lockers. 

Some facilities do not have individual patient prep 
rooms and, instead, use a large room (called pre-op 
holding) similar to the recovery room, with gurneys sep- 
arated by cubicle drapes for privacy (Figure 7-3). In this 
situation, patients sometimes change clothes within this 
enclosure, or they may use a dressing/locker room. It 
should be noted that JCAHO and state surveyors are 
especially interested in visual and auditory privacy for 
patients in pre-op and postanesthesia recovery units 
(PACUs). New facilities should not consider cubicle 
drape separation as an option but should construct pri- 
vate bays for each patient to address these standards 
(Figure 3-75). 

After the patient is undressed, the operative site is 
scrubbed, shaved, and prepped for surgery. The anesthe- 
siologist will interview the patient in the prep room or in 
the preoperative holding area, discussing the alternatives 
for anesthesia and answering any questions the patient 
may have. 

Most FOSCs do not use preoperative sedatives, as 
they increase recovery time. Therefore, patients may read 
or visit with their families prior to being taken to surgery. 
The patient may walk or be wheeled on a gurney into the 
operating room. Some facilities prefer to have patients 
walk in order to enhance their perception of being healthy 
and undergoing an elective procedure. 

Anesthetic induction almost always takes place in the 
operating room, although an intravenous fluid may be 



started in the preoperative holding area. Following sur- 
gery, the patient is transferred to the postanesthesia 
recovery area until he or she is conscious and stabilized. 
Many facilities use a second-stage recovery area that 
has recliner chairs and lounge seating (Figures 7-1 and 
7-4). Patients remain here after they are dressed, have 
some juice or tea, and leave when they feel well enough 
for discharge or when their escort has arrived. Often, the 
escort is allowed to sit with the patient in the secondary 
recovery area. Instructions for postoperative care may be 
delivered here or in a private office, adjacent to the dis- 
charge area. 



FACILITY ACCESS 

Handicap Requirements. Barrier-free access is a code 
requirement throughout the nation, and although patients 
are accompanied by staff in almost all areas of an ambu- 
latory surgical center, the facility must be designed to 
accommodate the disabled. 

Vehicular Access — Patient Pickup/Emergency. As 

the term ambulatory surgery implies, patients are able to 
walk into the facility without assistance. However, 
patients often leave a facility in a wheelchair, due to pro- 
tocols established by insurance carriers and regulatory 
agencies. The patient will be met by transportation at the 
facility's entrance or pickup area, which is often a private 
driveway located near the surgical center's discharge 
area. Optimally, patients and families should never have 
to backtrack through the facility. As the patient progress- 
es through the facility and ultimately to the secondary 
recovery and discharge area, the escort proceeds from 
the waiting room to the discharge area to greet the 
patient, and then goes to pull up the car at the patient 
pickup exit. 

When designing a medical office building with an 
ambulatory surgical center as a tenant, it is advisable to 
plan for a vehicular turnaround or drive-through, separate 
from the medical building lobby. This driveway must be 
large enough to accommodate an ambulance or a van. 



Facility Access 341 



I — ID O^y v~~y 




FIRST FLOOR 

5987 SF 



AMBULATORY SURGICAL CENTER 



Figure 7-1. Space plan for ambulatory surgical center on two floors, 12,936 square feet. (Design: Jain Malkin Inc.) 



342 Ambulatory Surgical Centers 



95-7" 




SECOND FLOOR 

6949 SF 



Facility Access 343 




FAR HILLS SURQ1GAL CENTER 

14813 SQ. FT. FLOOR PLAN 

Figure 7-2. Space plan for ambulatory surgical center, 14,813 square feet. (Design: Boulder Associates, Inc., Boulder, CO.) 



344 Ambulatory Surgical Centers 





\P'M& 



PASS THRU PASS THRU 

UTILITY 



WH p 



a 



""USE TOACE 

Q STATIONS 



|QES 




SUPPUES ■ 



AMBULATORY SURGICAL CENTER 

7312 SF 
Figure 7-3. Space plan for ambulatory surgical center with emergency-care facility, 7312 square feet. (Design: Jain Malkin Inc.) 



:e for 

EMERGI 

: faciu 

DR POS" 
AT1ENTS 



ENTRANCE FOR AFTER 

HOURS EMERGENCY 

CARE FACILITY 



Facility Access 345 




Figure 7-4. Space plan for ambulatory surgical center, 10,700 square feet. (Design: Boulder Associates, Inc., Boulder, CO.) 



346 Ambulatory Surgical Centers 



Facility Entrance. The building or facility entrance and 
passage to the reception area should be easily identifi- 
able, and should be pleasant and welcoming. If the 
patient has to hunt for the entrance, if signage is poor, or 
if the entry is poorly illuminated, it undermines the 
patient's confidence about the surgical experience. 

The building lobby or the waiting room of the FOSC 
must have a public telephone and a drinking fountain. 
Comfortable seating and current reading material should 
be provided for the patients' escorts. An outdoor court- 
yard or garden, accessible to the patients' companions, is 
a pleasant addition to the facility. If the FOSC is located 
on an upper floor of the building, at least one of the ele- 
vators must be large enough to accept a gurney and must 
have an override call button for emergencies. 

Physician/Staff Access. A physician/staff entrance 
should be provided near the staff lounge and locker 
area. Patients should not observe the coming and going 
of personnel. Dedicated physician parking close to 
the staff entry will be expected and appreciated by 
physicians. 

Service Access. Thought must be given to service access 
for pickup and delivery of laundry and for disposal of infec- 
tious waste and trash. Boxes of disposable supplies might 
be purchased in bulk lots and stored outside the surgical 
suite, replenishing the clinical area as needed. 



INDIVIDUAL COMPONENTS 
OF AN FOSC 




Figure 7-5. Registration area provides privacy. {Architecture and interior design: Shepley Bulfinch 
Richardson and Abbott, Boston, MA; Photographer: ©Peter Mauss/Esto.) 



Waiting/Reception Area 



The outpatient surgical facility is divided into three des- 
ignated areas — unrestricted, semirestricted, and 
restricted — defined by the activities performed there. 
Intermediate and major surgical procedure rooms must 
be located in the restricted area, whereas a minor surgi- 
cal procedure room may be located in the restricted or 
unrestricted area. This is discussed in more detail under 
Surgical Core. 



The patient's first impression of the surgical center will be 
formed in the waiting room. The patient should be able to 
reach the receptionist easily and be able to speak with a 
certain amount of privacy. The registration area, where 
scheduling and financial arrangements are made, must be 
private, quiet, and comfortable. Figures 7-1 and 7-5 show 
a registration area divided into privacy carrels. There is 
increasing awareness of the importance of patient privacy 



Individual Components of an FOSC 347 




Figure 7-6. Family/escort waiting area has appearance of library/lounge with slate-clad fireplace and wall of book- 
shelves. {Design: Jain Malkin Inc.; Photographer: Philip Prouse.) 



and confidentiality resulting from HIPAA (Health Insurance 
Portability and Accountability Act of 1999), which deals 
with electronic transmission of data. However, JCAHO and 
other accreditation agencies have extended this to the built 
environment in terms of acoustic and visual privacy. In 
addition, a public telephone, drinking fountain, restrooms, 
and wheelchair storage are required. 

The design of the waiting room enables the surgical 
center to demonstrate visually to patients its concern for 
their comfort. Colors should be cheerful, furniture com- 
fortable, and lighting appropriate for reading and/or relax- 
ing. Natural light and views of the outdoors should be 
exploited whenever possible. Figure 7-6 shows a waiting 



room with a fireplace, bookshelves, and seating arranged 
more like a living room, while Color Plate 27, Figure 7-7, 
has a coffee bar. Seating arranged in privacy groupings 
(Figure 7-8) is preferable to that which lines the perimeter 
of the room. Providing options and choices, according to 
a large body of research, reduces stress. Consider pro- 
viding a choice of environments such as a quiet room 
where family can read, another that has a TV built into an 
armoire or cabinet so that it doesn't dominate the room 
(Figure 7-9), and one with a protected play area for chil- 
dren with a built-in aquarium that can be viewed from the 
pediatric area as well as an adult lounge. A refreshments 
area with coffee and tea is welcomed by escorts dropping 
off patients for early-morning surgeries. Research also 
indicates that pleasant diversions greatly relieve stress — 
items such as water elements, aquariums, interactive 
art — things that distract the mind and cause relaxation. 

An ASC that is part of a large ambulatory-care center 
has the potential to provide, by virtue of scale, a number 
of attractive alternatives for waiting families. 

An outstanding design with an interior that provides 
numerous pleasant diversions, dynamic architecture, nat- 
ural light, and connects people to nature — even during 
robust Michigan winters — can be seen in Figure 7-10. 

Regional design features can flavor the decor. In San 
Diego, where residents are much enamored of Mexican 
culture, the high-tech aspects of ambulatory surgery were 
tempered with handcrafted folk art, colorful ceramic tile, 
and exuberant color (Color Plate 27, Figure 7-11). The 
ceiling of the registration area with a trellis and blue "sky" 
creates an outdoor ambience indoors (Color Plate 27, 
Figure 7-12). 

In some surgery centers, family are issued a beeper 
that enables them to shop, leave the facility to enjoy a 
meal, or sit in the garden, knowing that they will be 
"beeped" when the patient is in second-stage recovery. 



Waiting Room Capacity 

Waiting room capacity will be determined by the facility 
program. Most patients will be accompanied by a com- 



348 Ambulatory Surgical Centers 




Figure 7-8. Ambulatory surgical waiting area features privacy groupings and coffee bar 
at rear. Alpine Surgery Center. (Architecture and interior design: Boulder Associates, 
Inc., Boulder, CO; Photographer: Daniel O'Connor.) 



panion. Scheduling practices in an individual facility may 
cause last-minute rescheduling, necessitating a one- to 
two-hour patient wait in the waiting room. Turnover in an 
individual OR can be quite high, when taking into account 
that some procedures may only be 30 to 40 minutes in 
length. This means that a substantial number of patients 
and their companions may be in the waiting room at any 
one time, especially at peak scheduling periods. For 
example, patients who work often tend to schedule sur- 
gery on a Thursday or Friday so that they have the week- 
end to recover. Sometimes a small secondary family wait- 
ing room is provided for family or escorts near the sec- 
ondary recovery area and discharge exit. 




Figure 7-9. One area of the waiting room has a TV built into a cabinet with sloped magazine shelves 
alongside. This is the same facility as depicted in Figure 7-6. {Design: Jain Malkin Inc.; Photographer: 
Jain Malkin.) 



Individual Components of an FOSC 349 



Business Office 



[Image not available in this electronic edition.] 



The size of the business office will depend on the pro- 
gram established by the FOSC. The reader is referred to 
Chapter 3 for a discussion of the business office and 
related areas. Medical record storage is less extensive 
than in a physician's office since the patient's chart is 
retained by the referring physician, and only a brief med- 
ical history and a report of the surgical procedure are kept 
at the facility. Medical records must be protected from fire 
and unauthorized access. 

Scheduling is an important aspect of this enterprise. 
Scheduling staff use sophisticated computer software that 
is linked to a physician referral network, whereby patients' 
histories and preadmitting information are transmitted by 
computer, eliminating the need for the patient to be present 
prior to the day of surgery. ASCs often schedule blocks of 
time for individual physicians who use the facility regularly. 



Preadmit Testing 

Although not specifically part of an ambulatory surgical 
center, hospitals often have a preadmit testing area locat- 
ed either in the hospital or in an ambulatory-care facility. 
Patients are directed to this unit several days prior to sur- 
gery for "one-stop" presurgical testing, which may include 
blood tests, chest X-ray, ECG, verification of insurance 
and preauthorization, and completion of patient histories. 



Patient Examination/Prep Area 



Figure 7-10. Light-filled atrium with horticultural garden and koi pond provides a delightful waiting 
experience for families and escorts of ambulatory surgery patients. {Architecture and interior design: 
Shepley Bulfinch Richardson and Abbott, Boston, MA; Photographer: ©Peter Mauss/Esto.) 



The patient examination and prep area should be close to 
the waiting room and have a direct path to the operating 
rooms. Patient prep areas have a nurse station nearby 
(Figure 7-3) where patients may be weighed and their 
vital signs recorded. The patient will be supervised by the 
charge nurse, who reassures the patient during the 
preparation process and answers questions. 

In many facilities, the corridor leading to the patient 
prep area is clinical in appearance with portable medical 



350 Ambulatory Surgical Centers 



equipment and gurneys stored there, all of which may 
contribute to the patient's anxiety. It is desirable to create 
a nonclinical ambience, devoid of medical equipment clut- 
ter, using attractive vinyl wallcoverings, colorful sheet 
vinyl with inset geometric designs, and artwork. 

A preoperative or prep area needs a minimum of one 
bed per OR, varying as the facility program dictates. 
Individual prep rooms should be at least 8X10 feet in size 
(Figure 7-2). As discussed previously, a large room with 
privacy curtains dividing beds should not be considered 
in light of recent emphasis on patient visual and auditory 
privacy, but many existing facilities will have this (Figures 
7-3 and 7-4). Refer to Figure 3-75 for an optimal example 
of private treatment bays. Waiting for surgery (the antici- 
pation of the procedure) is the patient's time of highest 
anxiety; therefore, a chair for a family member should be 
provided. 

A nice touch in the prep and recovery areas is colored 
bed linens, accompanied by color-coordinated cubicle cur- 
tains, wallcoverings, and upholstery. Don't be afraid of 
color. This area need not be bland. Research shows that 
views of nature greatly reduce stress. The pre-op holding 
area in Figure 7-13 has a raised garden at gurney level on 
three sides and, in addition, a 2-x4-foot back-lit film trans- 
parency of tulip gardens over each bed. Color Plate 28, 
Figures 7-14 and 7-15, illustrate this concept in a proce- 
dure room and an OR, respectively. 

In many facilities, the preoperative holding area is 
used, later in the day, for recovering patients. If such is the 
case, each bed should be equipped with oxygen and suc- 
tion as well as patient monitors. 




Figure 7-13. Cardiac catheterization lab prep area surrounds patients with the stress-relieving benefits of nature in a 
garden that starts at the height of gurneys, wrapping around three sides of the room. Overhead, patients look at 
back-lit film transparencies of tulip gardens in Holland. Scripps Memorial Hospital, La Jolla, CA. (Architecture: 
Rodriguez and Park, San Diego, CA; Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.) 



Pediatric Patients 

If the facility will serve a significant number of pediatric 
patients, a number of factors should be considered. It is 
important for the parent to be able to accompany the child 
through as much of the process as possible. Dedicated 
pre-op holding and recovery areas (Figures 7-2 and 7-4 
and Color Plate 29, Figure 7-16) ensure that parents will 
not be infringing upon the privacy of adult surgical 
patients, nor will adult surgical patients be disturbed by 
the crying of children. 



Surgical Core 

The information in this section is largely based on the 
2001 edition of the AIA/USDHHS Guidelines for Design 
and Construction of Hospital and Health Care Facilities. 
Substantial changes have occurred with regard to outpa- 
tient surgical facilities since the 1996-1997 edition of the 
guidelines, which was much more general and not nearly 
as detailed in regard to specific rooms and areas. The 
essay at the front of the 2001 Guidelines states: "There 



Individual Components of an FOSC 351 



has been a concerted effort to level the playing field and 
to give patients the same level of protection for surgical 
procedures whether they are performed in an acute gen- 
eral hospital or in an outpatient setting." Two specific 
areas of change relate to the classification of operating 
rooms according to three levels of care as defined by the 
American College of Surgeons. This incidentally corre- 
lates with the three classifications (A, B, and C) of anes- 
thesia used by AAAASF. Refer to Chapter 4, Plastic 
Surgery, for a description of these classifications. Another 
change in the new guidelines that should be noted relates 
to the soiled workroom, which can no longer have a pass- 
through to the clean assembly workroom. 

American College of Surgeons Classification ofORs 

The sizes of ORs stipulated in the 2001 AIA Guidelines are 
based on levels of care defined by the American College 
of Surgeons. The italics indicate the ACS class descrip- 
tions, followed by the Guidelines sizes for outpatient ORs. 

Class A. "Provides for minor surgical procedures per- 
formed under topical and local infiltration blocks with or 
without oral or intramuscular preoperative sedation. 
Excluded are spinal, epidural axillary, stellate ganglion 
blocks, regional blocks (such as interscalene), supraclav- 
icular, infraclavicular, and intravenous regional anesthe- 
sia. These methods are also appropriate for Class B and 
C facilities." 

(Minor surgical procedure rooms) shall have a mini- 
mum clear area of 120 square feet, a minimum clear 
dimension of 10 feet, and minimum clear distance of 3 
feet at each side, head, and foot of table. May be located 
within a restricted or unrestricted corridor. 

Class B. "Provides for minor or major surgical procedures 
performed in conjunction with oral, parenteral, or intra- 
venous sedation or under analgesic or dissociative drugs." 
(Intermediate surgical procedure rooms) shall have a 
minimum clear area of 250 square feet with a minimum 
clear dimension of 15 feet, minimum clear distance of 3 
feet, 6 inches on all sides of the table. Must be located 
within restricted corridors of the surgical suite. 



Class C. "Provides for major surgical procedures that 
require general or regional block anesthesia and support 
of vital bodily functions." 

(Major surgical procedure rooms) shall have a mini- 
mum clear area of 400 square feet, a minimum clear 
dimension of 18 feet, and minimum clear distance of 4 
feet on all sides of the table. Must be located within 
restricted corridors. 

The number of first-stage and second-stage recovery 
stations required is related to the number of each class 
level OR in the AIA Guidelines. 

Control Station/Nurse Station 

The nerve center of the surgical core is the nurse station. 
It provides visual surveillance of all traffic entering the 
restricted corridor and commands total visual control of 
the area, including OR doors and surgical core access. 
There may be another nurse station in the pre-op holding 
area and in the recovery room. 

The nurse station should be large enough to allow ade- 
quate staff work space to monitor activities. It should con- 
tain a built-in blanket warmer in the casework and a sink 
and a locked drug storage cabinet or medications closet. 
The area will contain a crash cart (emergency resuscita- 
tion), wheelchair, and gurney storage. 

Unrestricted, Semirestricted, and Restricted Areas 

According to the 2001 edition of the AIA Guidelines, the 
unrestricted area includes a central control point (recep- 
tion desk) established to monitor entry to the semirestrict- 
ed and restricted areas. The semirestricted area includes 
the peripheral support spaces of the surgical suite and 
has storage areas for clean and sterile supplies, work 
areas for storage and processing of instruments, and cor- 
ridors leading to the restricted areas of the surgical suite. 
Traffic here is limited to authorized personnel and patients 
who must wear surgical attire and cover head and facial 
hair. The restricted area includes operating and procedure 
rooms, the clean core, and scrub sink areas. Surgical 
attire and hair covering are required and masks must be 
worn where open sterile supplies are located and where 
contact with persons who have scrubbed may occur. 



352 Ambulatory Surgical Centers 



The path to the operating rooms should be direct and 
as aesthetically pleasant as possible, maintaining consis- 
tency with the aesthetic ambience of the prep area, which 
by now will have become familiar to the patient. Although 
a sterile (restricted) zone is far more limited in terms of 
allowable finish materials, color and detailing may still 
reiterate the theme. Careful attention to detail, the use of 
oak trim, and the colorful ceramic tile in Color Plate 29, 
Figure 7-17, reinforce an image of quality. 

The sterile corridor functions as a transition, separating 
operating rooms from patient prep and recovery. It should 
never be entered in order to reach another destination. 
Surgical apparel must always be worn in this corridor, and 
unprotected street clothes are not permitted. 

Scrub Area 

Scrub sinks (with knee- or foot-activated controls) are 
located near the entrance to each OR (Figure 7-18). State 
codes establish the specific number of sinks per OR, 
which is usually two per OR for the first two and one addi- 
tional sink for each additional OR beyond two. These 
should be positioned to prevent splashing of personnel or 
equipment. They are usually recessed in a niche lined 
with floor-to-ceiling ceramic tile or other stain-resistant 
material. A clock must be visible from each scrub sink, 
and the OR door should push into the room to prevent 
personnel from using their hands to pull it open. 
Additionally, doors into ORs should be visible from the 
control or nurse station (Figure 7-2). 

Operating Rooms 

Operating room design requires the consideration of 
many factors, as described below. 




Figure 7-18. Scrub corridor. Beautiful detailing and unusual design features characterize this facility. Also see Color 
Plate 29, Figure 7-1 7. {Photo courtesy: Anderson Mikos Architects, Ltd., Oak Brook, IL; Photographer: Jay Wolke.) 



Size. There seems to be a rule of thumb for economic 
viability of an FOSC, which necessitates at least three 
ORs. With required support services, this translates to 
approximately 10,000 square feet. The sizes for Class 
A, B, and C ORs in the AIA Guidelines were stated pre- 
viously. In other codes and standards, the minimum size 
of a minor OR is 270 net square feet, with a 15-foot 
minimum dimension across the room. The minimum 



size for a major OR is 350 net square feet, with an 18- 
foot minimum dimension across the room. It is prudent 
to size ORs larger than may have been anticipated in 
order to accommodate additional portable equipment 
such as microscopes for ophthalmic surgery, arthro- 
scopes, lasers, video monitors, C-arm X-ray, and robot- 
ic devices that are becoming standard as ambulatory 



Individual Components of an FOSC 353 



[Image not available in this electronic edition.] 



Figure 7-19. State-of-the-art operating room uses ceiling-mounted articulating arms to facilitate quick repositioning of 
equipment. Ambulatory Care Center at Branson Methodist Hospital, Kalamazoo, Ml. (Architecture: Shepley Bulfinch 
Richardson and Abbott, Boston, MA; Photographer: ©Peter Mauss/Esto.) 



surgery takes on an expanded role. As time goes on, 
more procedures will be done on an outpatient basis 
and more complicated types of surgery will be per- 
formed in an FOSC. 

Hospital inpatient ORs are generally 400 net square 
feet or larger. That size allows for great flexibility and 
space for a number of OR personnel and equipment. 



Room shape should be as close to square as possible for 
convenient placement of mobile and ceiling-mounted 
equipment around the table. Figures 7-19 and 7-20 show 
typical ASC operating rooms. The extraordinary ceiling 
design in Color Plate 28, Figure 7-15, connects patients 
to nature, distracting and relaxing them prior to anesthe- 
sia induction. Operating rooms in an FOSC should be 
designed to the same exacting standards as hospital 
inpatient ORs. Precautions for infection control, fire safe- 
ty, equipment performance, lighting design, airflow, gas 
shutoff, and electrical back-up power should all be care- 
fully considered. 

Planning Issues. Operating room features that affect 
turnaround time between procedures deserve careful 
examination. The typical inpatient OR may be used for 
three or four procedures per day, each of which may last 
two to four hours, whereas an FOSC OR may be used six 
or seven times per day for procedures lasting 30 to 90 min- 
utes. In an FOSC, surgery generally terminates by 2 p.m. to 
enable patients to recover and leave by closing time. 

In this regard, the route between the operating rooms 
and sterilization and the manner in which instruments 
and sterile supplies are delivered to the room become 
significant. Some facilities have a separate sterile corri- 
dor (Figure 7-3) around the operating room for flash 
sterilization and for quickly supplying the operating 
rooms. This is a matter of individual consideration, 
based on the surgical program and available space. 
(Note that the facility in Figure 7-3 functions as an after- 
hours emergency-care facility.) Staff input on design of 
the OR is critical in laying out the rooms so that gas 
lines, suction, electrical, and computer access are prop- 
erly placed. Location of the sterile field should be part of 
this discussion. 

Casework in operating rooms either should be 
recessed in the wall (Figure 7-19) or, if freestanding, 
should have a sloped top to avoid a shelf that becomes a 
dust collector. Operating room casework usually has 
glass doors for viewing the contents (Figure 7-19). 



354 Ambulatory Surgical Centers 




Figure 7-20. State-of-the-art laparoscopic operating room equipped with video-laparoscopic surgery "towers" suspended from the ceiling by power booms (articulating arms) to keep floor clear of 
clutter. (Photo courtesy: Hacksensack University Medical Center, Hackensack, NJ) 



Individual Components of an FOSC 355 



Equipment. The operating room is on its way to becom- 
ing an ultra-high-tech environment, integrating voice 
recognition systems, robotics, and PACS, and there will 
be more blurring of the line between interventional radiol- 
ogy and surgery as vascular radiology, neuroradiology, 
and cardiology become more invasive. CIMIT (the Center 
for Innovative Minimally Invasive Therapy, a partnership 
between the Massachusetts Institute of Technology, 
Massachusetts General Hospital, and Brigham and 
Women's in Boston) is currently designing a minimally 
invasive surgery suite using remotely controlled robots to 
execute the procedures laparascopically. As an example, 
a coronary artery bypass graft (CABG), in the conven- 
tional procedure, involves opening the rib cage. But, when 




Figure 7-21. Surgeons at work in state-of-the-art operating room designed for minimally invasive surgery. Surgeons 
wear microphones to control voice-activated robots. (Photo courtesy: Hacksensack University Medical Center, 
Hackensack, NJ.) 



executed robotically, it can be performed endoscopically 
through a small opening and the patient can be playing 
golf just three days later, without the pain, loss of produc- 
tivity, and rehabilitation required with the standard proce- 
dure. CIMIT is evaluating, among other things, whether 
the robotic control station for the surgeon should be in a 
remote location or within the room. In these high-tech 
ORs, the pieces of equipment will "talk" to each other. A 
nurse's desk for computerized charting also needs to be 
accommodated. 

It is likely that ambulatory surgery centers associated 
with academic medical centers may well be the first to 
embrace and invest in this level of technology. The 
Hackensack University Medical Center, at the end of 
1998, opened a new ASC featuring 10 state-of-the-art 
laparascopic surgery operating rooms. Each is equipped 
with video-laparascopic surgery towers suspended from 
the ceiling by Berchtold Teletom® power booms, which 
neatly conceal electrical cables, gas lines, and video 
cables, removing the clutter of multiple cables and wiring 
as well as equipment, from the floor, mounting it on these 
articulating arms and shelves (Figure 7-20). In these 
ORs, various components of the electronic video equip- 
ment for laparascopic operations are integrated through 
the use of a voice-activated robot called Hermes®. The 
surgeon wears a microphone and controls all of the 
equipment through various voice commands. The sur- 
geon is assisted by a second voice-operated robot called 
Aesop®, which holds the video camera and points it in dif- 
ferent directions (Figure 7-21). At Hackensack, patients 
are assigned a day accommodation room where they 
change gowns and are interviewed by the nurse and 
anesthesiologist prior to walking to the OR. After anes- 
thesia recovery, patients return to this same dayroom to 
be rejoined by their family (Figure 7-22). 

The new (opened in 2000) Ambulatory Care Center at 
Branson Methodist Hospital in Kalamazoo, Michigan, also 
makes use of the Berchtold power boom, which allows for 
quick repositioning of equipment (Figure 7-19). 

Electrical Systems. The electrical system must meet 
standards established by the National Electrical Code, 



356 Ambulatory Surgical Centers 



NFPA 70; Essential Electrical Systems, NFPA 99; Use of 
Electricity in Patient Care, NFPA 99; and state codes. The 
AIA/USDHHS Guidelines for Construction and 
Equipment of Hospital and Health Care Facilities gives a 
brief description of requirements with references to the 
aforementioned codes. 

The electrical system in any facility where general 
anesthesia is used is very complex and an electrical engi- 
neer experienced in healthcare design should be part of 
the design team. Code-mandated items include an alarm 
system, emergency power, ground-fault protection, nurse 
call and communication systems, and possibly an isolat- 
ed power system. All ORs must have an emergency com- 
munication system connected to the control station. 

Electrical outlets in the OR should be mounted at waist 
height, when located on the wall. Outlets overhead are 
practical as cords are less likely to become tangled. 

Mechanical System. Air-handling systems (HVAC) in the 
OR and other areas of a surgical suite are very specifi- 
cally regulated, and they require the technical expertise 
of a mechanical engineer experienced in healthcare 
design. The AIA/USDHHS Guidelines give a detailed 
description of requirements in various areas of the suite 
and refer the designer to applicable NFPA codes that 
form the basis for regional requirements. 

Simply stated, airflow in an OR should be from "clean" 
to "less clean" areas. Air should enter the room at the ceil- 
ing, above the patient, and be drawn off at two or more 
widely spaced locations near the floor. Filtration, number 
of air changes per hour, volume, humidity, and tempera- 
ture are specifically mandated. In some circumstances, 
where the potential for infection is high, a laminar airflow 
system may be used. This system sends a large volume 
of slow-moving, nonturbulent, filtered air down over the 
patient and the operating team, preventing any particles 
from settling on the wound. 

An enhancement of this concept is the Steriflo® system 
by Krueger in Richardson, Texas. Forced sterile air, which 
is comfort conditioned to specific surgical requirements, 
creates a cube from ceiling to floor surrounding the 
patient and the surgical team. Contaminated air between 




Figure 7-22. Private day rooms assigned to each surgical patient are used for changing clothing, 
clinical interviews, and second-stage recovery where patient is rejoined by family. (Photo courtesy: 
Hacksensack University Medical Center, Hackensack, NJ.) 



the actual operating area and the four walls of the oper- 
ating room impinges, but cannot penetrate, the curtain of 
sterile air and is immediately exhausted through the 
return air system. The curtain of sterile air is forced 
through pressure plenums and filtered downward through 
slot diffusers positioned in the ceiling around the operat- 
ing table. 

Operating rooms must maintain positive air pressure to 
keep contaminants from being sucked into the room 
when the door is open. Air inputs at the ceiling, with 



Individual Components of an FOSC 357 



exhausts at the base, ensure that contaminants from the 
floor are not carried up to the sterile field. 

Room temperature and humidity affect each other and 
therefore must be reviewed accordingly. Relative humidi- 
ty higher than 60 percent with a temperature in excess of 
72 degrees Fahrenheit can create condensation, while 
relative humidity lower than 50 percent at 72 degrees 
Fahrenheit can create static electricity. 

Lighting. Recommendations for lighting levels have been 
established by the Illuminating Engineers Society in its 
publication, Lighting for Hospitals and Health Care 
Facilities. In an operating room, general room illumination 
is provided by flush-mounted fluorescent fixtures (with 
dimmer controls), which give 200 footcandles of intensity 
at the work surface. Fluorescent lamp color, to match the 
surgical light, should be at a color temperature of 4200 to 
5000 kelvins with a CRI (color rendering index) of 85 to 
90. Ceiling-mounted surgical lights must produce tremen- 
dous brightness (illuminance up to 260,000 lux), high 
color contrast for tissue definition, shadow-free lighting, 
and excellent color rendition with a CRI of 85 to 90. 

The quantity of light is of equal importance to the qual- 
ity of light, with reference to issues of glare, contrast, color 
rendering, surface reflectance, and dimming capacity. 

Videoscopy is sometimes enhanced by the lowering of 
light levels. When using microscope illumination, fluores- 
cents and operating lights may be dimmed. (The sur- 
geon should be able to control room lights with a foot 
switch or voice command.) Auxiliary downlights, located 
where they will not be distracting, provide lighting for 
nurses and the anesthesiologist when surgical lights 
have been dimmed. 

Medical Gases. Medical gases include oxygen, com- 
pressed air, vacuum (suction), nitrous oxide, and nitrogen 
(used for power instruments). These are centrally piped to 
each operating room and may be delivered by an outlet in 
the wall, through a fixed column extending from the ceil- 
ing, or via a movable track. Medical gases are used by 
both the anesthesiologist and the operating team; sepa- 
rate outlets are needed for each. 



Oxygen and suction are also required at each recovery 
bed. The endoscopy procedure room needs oxygen, 
compressed air, and suction. The endoscopy workroom 
needs compressed air and suction. Refer to Chapter 3, 
Endoscopy, for details of workroom design. 

A gas scavenging system to "clean" room air of any 
anesthesia gases is required in any OR using inhalation 
anesthesia. The AIA/USDHHS Guidelines list require- 
ments for each area of the surgical suite. 

Use of Lasers. Lasers have become standard equipment 
in operating rooms. Different types of lasers, and how 
they function, are explained in Chapter 4 under 
Ophthalmology. The holmium and Nd:YAG laser called 
the VersaPulse® Select™ by Coherent Medical Group is 
commonly used for urology, orthopedics, ENT, and other 
specialties. Figure 4-116 is actually an erbium laser used 
by dermatologists for skin resurfacing, but it looks, from 
the exterior, the same as this manufacturer's holmium 
Nd:YAG. The small laser in Figure 4-161 operates on 
standard electrical service and is used for ENT, gynecol- 
ogy, urology, and general and aesthetic surgery; however, 
many lasers have higher power requirements. The laser 
in Figure 4-115 is a C0 2 laser, commonly used by gyne- 
cologists, general surgeons, and plastic surgeons, 
although the specific model depicted is an aesthetic laser 
system used by dermatologists and plastic surgeons. The 
surgical C0 2 (by the same manufacturer) used in multiple 
types of surgery looks exactly the same, however. The 
laser in Figure 4-84 is a Nd:YAG type, commonly used by 
ophthalmologists and otolaryngologists. 

The ability of lasers to cut precisely, vaporize tissue, 
and coagulate blood has revolutionized surgical tech- 
niques. Certain procedures that were routinely preformed 
in an operating room may now be done in a physician's 
office, which illustrates that lasers are very much a part of 
ambulatory care. Valuable though they are, lasers do 
require thorough understanding and respect for associat- 
ed occupational hazards. 

Two major occupational hazards associated with lasers 
are exposure to the eyes and skin and toxic fumes, espe- 
cially the C0 2 laser plume, about which much has been 



358 Ambulatory Surgical Centers 




Figure 7-23. Laser smoke evacuation system with Fresh Aire ULPA fil- 
ter. (Photo courtesy: Stackhouse Inc., A Thermo Respiratory 
Company, Palm Springs, CA.) 



written. Standard surgical masks are ineffective as a pre- 
caution against inhaling the minute particulate matter in 
the laser plume. Standard surgical masks filter out parti- 
cles down to 5 microns in size, whereas particulate mat- 
ter in the laser plume goes down to 0.3 micron in size. 
The Association of perioperative Registered Nurses 
(AORN) and the National Institute of Occupational Safety 
and Health (NIOSH) have determined that laser and elec- 
trosurgical smoke is hazardous and may expose OR per- 
sonnel to aerosolized infections, viruses, toxic gases, and 
vapors. 

The laser smoke filtration system in Figure 7-23 suc- 
tions the laser plume and filters particles as small as 0.12 
micron. It also helps to control the odor of vaporized tis- 
sue. This unit is designed for office-based surgery suites 
in physicians' offices but can also be used in an ASC. A 
new model, the VitalVac™ by Stackhouse®, has many 
useful features for the ASC OR. Note that in ORs the 
motor and blower may be placed in the power column and 
above the ceiling (not visible), while the filter and keypad 
are exposed on a shelf. 



The American National Standards Institute (ANSI) doc- 
ument Z-136.1 (may be purchased from the Laser 
Institute of America in Florida, www.laserinstitute.org) 
describes four basic categories of controls that should be 
employed in laser environments. These involve engineer- 
ing controls, personal protective gear, administrative and 
procedural protocols, and special controls. Personal pro- 
tective equipment includes goggles, clothing, gloves, and 
laser masks, depending on the type of laser and the 
amount of laser radiation emitted. 

All windows in operating rooms or glazing in doors 
must be covered during laser procedures, as some laser 
beams can pass through glass. Appropriate warning 
signs must be placed on doors to ORs when lasers are in 
use. Nondefeatable entryway controls may be required on 
OR doors to prevent people from entering when lasers 
are in use. Safety interlocks that disable the laser beam 
are standard on all laser systems. These allow an electri- 
cal connection to a door, for example, when it is opened 
during laser use to immediately put the laser into standby 
mode. 

As infrared and ultraviolet laser beams are invisible, 
manufacturers must do something to make them visible. 
A red aiming beam is coaxially aligned with the invisible 
treatment beam to solve this problem. 

Some lasers have special power requirements (208- to 
220-volt, three-phase power), but many function with 
standard current. ANSI Z-136.3 specifically deals with the 
use of lasers in the medical environment. This is required 
reading for anyone designing facilities where lasers will 
be used. 

Equipment Storage. An equipment room convenient to 
the ORs should be provided for the storage of lasers. If 
they are stored in the OR, one has to plan well in advance 
to move them to the OR where they will be needed next. 
If they are all kept in one OR, dedicated strictly to laser 
surgery, scheduling and flexibility can become a problem. 
Since only one procedure can be done at a time, the 
other lasers in the room would be unusable. Other types 
of equipment might also be stored in this room, such as a 
C-arm X-ray machine. 



Individual Components of an FOSC 359 



Accessory Items. Operating rooms will have two clocks 
with second hands (one for tracking elapsed time) and a 
recessed X-ray film illuminator. An individual room may 
have a C-arm fluoroscopic X-ray unit with TV monitor; there 
may be a number of ceiling-mounted monitors, a ceiling- 
mounted microscope, and a number of portable pieces of 
equipment, including an emergency resuscitation cart. 
Each piece of equipment has specific power requirements, 
which must be carefully coordinated between the equip- 
ment suppliers and the electrical engineer. A structural 
engineer should be consulted to ensure that all ceiling- 
mounted equipment is adequately supported. A Unistrut 
system above the finished ceiling is usually required. 

Overhead Utilities. The designer must provide enough 
space above the finished ceiling to accommodate struc- 
tural support, HVAC ducts, recessed fluorescent lighting, 
electrical conduits, and medical gas piping. The finished 
ceiling height in an OR should be 10 feet plus another 2 
feet in the plenum above. It is sometimes difficult to 
achieve this height within the structure of the standard 
medical office building. 

Interior Finishes. Finish materials used in the OR must 
be very durable and able to be cleaned with strong, ger- 
micidal agents. Materials should be monolithic and free of 
seams. Frequent, harsh cleanings tend to open seams, 
which then harbor microorganisms. 

Floors. ORs often used to have terrazzo floors. This is an 
excellent material, but in today's market, it is expensive 
and not adaptable to remodeling. A high-quality cush- 
ioned sheet vinyl with heat welded or chemically welded 
seams is ideal for ORs. Attractive products are available 
that can be cut and inlaid with contrasting borders (Figure 
7-19). Sheet vinyl should be installed with a self-coved, 6- 
inch-high base. Conductive flooring is not required unless 
flammable anesthetic gases are used. 

The reason surgical scrubs (attire) are green is to neu- 
tralize the afterimage of blood, since green and red are 
opposite each other on the color wheel (see Chapter 1 1 ). 
After staring at the surgical field (red) when one looks 



away, the eye produces the complementary color (green). 
To avoid seeing green "spots," an 8-x8-foot inset of green 
sheet vinyl set into the floor neutralizes the afterimage 
and is also attractive. 

Walls. For years, operating rooms had ceramic tile walls, 
usually in surgical green color. Largely for cost consider- 
ations, epoxy paint (specify dull sheen) has become more 
common in recent years. If ceramic tile is used, it must 
have a nonreflective matte finish and should be of a medi- 
um color value (less reflective for lasers), rather than 
light. Grout joints must be flush, and latex grout should be 
considered. 

Ceilings. Operating room ceilings must be smooth and 
washable. Gypsum board with a washable, nonreflective 
finish in a light to medium color tone is recommended. 
Ceilings in semirestricted areas, such as clean corridors, 
central sterile supply, radiographic rooms, and minor pro- 
cedure rooms, must be smooth, scrubbable, and capable 
of withstanding germicidal cleaning. 

Pathology Prep Area 

A small room with cabinet and undercounter refrigerator 
may be provided for storing tissue to be sent to a pathol- 
ogy lab. Prepared vials containing formalin to preserve 
the tissue are taken into the OR and later must be refrig- 
erated until pickup. These can also be stored in a fridge in 
the soiled workroom. 

Endoscopy and Minor Procedure Rooms 

Ambulatory surgical centers often have an endoscopy 
suite (Figure 7-1 ). Specific design details are discussed in 
Chapter 3 under Internal Medicine. This room can be 
used for other types of minor procedures that require a 
clean, but not a sterile, environment. 

A 12x12-foot or 12x14-foot procedure room is often 
used for procedures where minimal assistance is needed 
and where either no anesthesia, local anesthesia, or con- 
scious sedation is indicated. In the AIA Guidelines, a 
Class A room need only be 120 square feet, but this 
would be too small for endoscopy procedures. The guide- 



360 Ambulatory Surgical Centers 



lines define a procedure room as having a clear area of 
200 square feet exclusive of fixed cabinets and must have 
a freestanding hand-washing station nearby. This is the 
size room designated for endoscopy procedures. 

Workrooms 

The movement of clean and soiled instruments and mate- 
rials through the surgical suite should be as efficient and 
economical as possible and must be carefully studied 
during the programming stage of design. There must be a 
continual flow of clean disposable supplies, linens, and 
instruments into, and removal of soiled items from, the 
OR. Provision should be made for computer monitors in 
workrooms to track instruments and manage a number of 
functions. 

Soiled Workroom. Instruments leaving the OR go direct- 
ly to a soiled workroom where they are decontaminated 
prior to sterilization. Here they are soaked, scrubbed, 
rinsed, and/or placed in ultrasonic cleaners to remove 
blood and debris. This room requires a clinic (flush) serv- 
ice sink, deep utility sink, built-in washer/sterilizer, coun- 
tertop work surface, and storage for sorting soiled mate- 
rials (Figure 7-24). A washer decontaminator that goes 
through the wall into the clean assembly workroom allows 
dirty instruments to be put in on one side and removed, 
after processing, on the other where they are put into peel 
packs for visualization or wrapped and labeled into kits 
prior to terminal sterilization (Figures 7-1 and 7-2). The 
lighting level recommended by the Illuminating Engineers 
Society is 100 footcandles. 

It should be noted that the previous edition of the AIA 
Guidelines "allowed" pass-through doors, creating an 
opening between soiled and clean workrooms, but the 
2001 edition eliminates this. 

Soiled Holding. This is an area for the collection, stor- 
age, and disposal of soiled materials, including linen, and 
hazardous waste. 

Clean Assembly/Workroom. This room is used for 
inspecting, assembling, and wrapping instruments after 




Figure 7-24. Soiled workroom with clinic service "flush" sink and sterilizer. {Design: Jain Malkin Inc.; 
Photographer: Jain Malkin.) 



they have been washed and decontaminated, and for ter- 
minal sterilization of medical and surgical equipment and 
supplies. This room requires a handwash sink, adequate 
countertop work surfaces, and sufficient storage to accom- 
modate supplies. Access should be convenient to the ORs. 
Smooth and washable floor and wall finishes are required. 

Sterilization. Sterilization takes place in the clean 
assembly/workroom but may additionally be done in a 
substerile area, which is a small room adjacent to an OR, 
or sometimes between two ORs (Figure 7-2), with an 
autoclave for quick "flash" sterilization between proce- 
dures. Typically, there is a central location serving all ORs 
supplemented by decentralized sterilization (Figures 7-1 
and 7-4), although, in Figure 7-3, the primary and only 
sterilization area wraps around the ORs. Substerile areas 



Individual Components of an FOSC 361 




Figure 7-25a. Clean workroom and supply. (Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



allow easy access for flash sterilization (pre-vac comput- 
erized sterilization takes only 3 to 10 minutes per cycle 
and is used between cases). It's a good idea to provide 
small blanket warmers in the substerile areas so that a 
warm blanket can be put around the patient as soon as 
he or she is settled on the operating table since ORs are 
always very cold. 

Whatever the configuration, the sterilization room will 
contain a large, high-speed autoclave, a Steris peracetic 
acid sterilizer for heat-sensitive items (requires plumbing) 
that sterilizes items in 30 minutes, Chemiclave (steam 
autoclave that uses chemical solutions instead of water), 
dry heat sterilizer, sink, adequate countertop work sur- 
faces, and storage of clean materials needed to restock 
the ORs. Cleaning, packaging, sterilization, and setup of 
surgical trays is done here. It should be noted that the 
ETO (gas) sterilizer releases toxic vapors that must be 
exhausted to the outdoors; however, ETO is being 
phased out. Ventilation issues should be examined care- 
fully in a sterilization area. Wall finishes and flooring 
should be smooth and washable. 




Figure 7-25b. Clean workroom and supply. (Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Clean/Sterile Supply Room. After instrument kits have 
been removed from terminal sterilization, they are 
allowed to cool before being stored in a clean environ- 
ment convenient to the OR. Adequate open-shelf storage 
should be provided (Figures 7-25a and 7-25b), where 
humidity from the sterilizer is not a factor. 

Anesthesia Workroom. A dedicated anesthesia work- 
room is required if Class C ORs exist. Anesthesia equip- 
ment is cleaned, tested, and stored in this room. At least 
one compressed-air outlet and one oxygen outlet are 
needed at the work surface. 

A sink is required along with sufficient storage for sep- 
arating soiled from clean equipment. All surfaces must be 
easily cleanable. 

Housekeeping Room. The surgical core must have its 
own housekeeping room, even if one is located else- 
where in the suite. It will need a floor sink and storage for 
all cleaning supplies, materials, and equipment. 



362 Ambulatory Surgical Centers 



Storage of Medical Gases 

Storage of medical gases must be evaluated in terms of 
convenient access, separation from other areas (fire 
hazards), and security. A room near the service entry is 
generally convenient. Gas storage may be outside the 
facility, if securely protected from vandalism. Building 
codes often require wall construction of two-hour fire 
rating around the room, one-hour duct protection, 
smoke-fire damper at air supply into the room, and a 
90-minute rated door. Other requirements such as an 
alarm and automatic extinguishing equipment may 
be required, based on location and type of gases used. 
The room must be vented directly to the outdoors. Fire 
codes are very specific with respect to the storage and 
handling of medical gases. The designer is referred 
to NFPA 99C, Standard on Gas and Vacuum Systems 
(1999). 

Vacuum and Compressed Air 

Vacuum (suction) and compressed air are provided by 
compressors located on site. These may be remotely 
located, limited only by flow resistance in the supply pipe. 
Sometimes a basement, a rooftop, or an outlying utility 
pen may be utilized. 

These compressors are very noisy and should be 
properly installed to isolate vibration and noise. 

Staff Areas 

The design of staff areas may vary. The main factors to 
consider are outlined in the following sections. 

Dressing/Locker Rooms. Facilities for medical staff to 
change into surgical attire should have adequate space 
for storage of scrubs in various sizes, caps, and shoe 
covers as well as receptacles for soiled linen and dispos- 
able items (Figure 7-26). Separate male and female facil- 
ities must be provided, including lockers, showers, toilets, 
and handwash stations. The design should create a one- 
way traffic pattern so that personnel entering from outside 
the surgical suite can change and eventually exit into the 
restricted area. 




Figure 7-26. Staff dressing area with storage for surgical apparel and 
a bin for soiled garments. {Design: Jain Malkin Inc.; Photographer: Jain 
Malkin.) 



Individual Components of an FOSC 363 




Figure 7-27. Staff lounge, with kitchen. (Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Waste/Trash Disposal. A provision for fluid waste dis- 
posal (clinic flush sink) convenient to the ORs and 
postanesthesia recovery unit is required. The one in the 
soiled workroom may be used, provided, in addition, one 
toilet in the recovery area is equipped with a bedpan 
cleaning device. 

Lounge. A staff lounge with kitchen should be provided 
for surgical personnel to allow them to relax between pro- 
cedures without having to regown (Figure 7-27). This area 
is not considered "clean" in terms of maintaining sterile 
conditions such as exist in the surgical core. Walls may 
have vinyl wallcovering, and a suspended acoustical ceil- 
ing may be utilized. The type of furniture in this area is not 
specifically addressed in codes or guidelines; however, 



AORN recommends upholstered furniture and carpeting, 
provided a good maintenance program is enforced. 
Sometimes the lounge has carrels to enable physicians to 
dictate and chart. These functions can also be accommo- 
dated in a dictation room in the OR area. 

The lounge should be a comfortable, softly illuminated 
room, with space for dining as well as lounging. 
Telephones are necessary, as well as a tackboard for 
posting notices of clinical or social importance to the staff. 
If natural light is available it should, by all means, be 
exploited. The surgical staff lounge in Figure 7-28 has 
clerestory windows, admitting light that is reflected by a 
mirror down into the room. The staff lounge is a high-traf- 
fic area used throughout the day. 

Postanesthesia Recovery (Primary) 

The patient's destination from the OR is the postanesthe- 
sia recovery room. This should be immediately accessible 
from the central sterile corridor. Economies, with respect 
to staffing, may be achieved by designing the pre-op hold- 
ing area immediately adjacent to the recovery room, with 
a single large nurse station overlapping the two areas. 

The AIA Guidelines define the number of recovery sta- 
tions as follows: 

Class A: minimum of one bed per OR with 2 1 / 2 feet clear 
on three sides of bed 

Class B: minimum of two beds per OR with 3 feet clear 
on three sides of bed 

Class C: minimum of three beds per OR with 4 feet 
clear on three sides of bed. 

Prior to the new Guidelines, two recovery beds per OR 
was common with an area allocated for each bed (inside 
the cubicle curtain), of at least 80 square feet, allowing at 
least 3 feet on all sides of the bed for work space and/or 
circulation. A patient is generally alert enough to be 
moved to second-stage recovery in about an hour. 
Theoretically, this would allow for two procedures per 
hour in each OR. Recovery room capacity may be adjust- 
ed higher or lower, depending on the program and the 



364 Ambulatory Surgical Centers 



experience of the medical staff. Privacy between beds 
may be achieved by glass walls with cubicle drapes 
although glass will result in a noisier environment than 
standard gypsum board partitions. 

The level of asepsis control measures applied in this 
area is based on licensing and accreditation guidelines. A 
sheet vinyl flooring is recommended for the high volume 
of wheeled traffic and also to facilitate cleanup if someone 
vomits. 

Indirect lighting is ideal, adjusting light levels lower over 
recovery beds and higher at the nurse station. The area 
should be colorful, but avoid busy patterns or bold colors, 
which may cause discomfort if a patient is nauseated. 
Cubicle drapes are probably the best vehicle for accent 
color, as they are easily changed. The color of fluorescent 
lamps in this area is a critical factor, as skin tone is an indi- 
cator of the patient's condition. A color temperature of 
3500 kelvins with a CRI of 85 to 90 is recommended. 

The nurse station must have good visibility of all beds 
(Figure 7-2) and must have a handwashing sink, emer- 
gency resuscitation cart, lockable drug cabinet, wheel- 
chair storage, and staff and patient toilets. 

It is unlikely that an isolation recovery room for a single 
occupant would be required in an FOSC. However, occa- 
sionally facilities have private recovery rooms as in Color 
Plate 29, Figures 7-17 and 7-29, and Figure 3-76. To 
increase the perception of natural light in the basement- 
level recovery room, shown in Color Plate 29, Figure 
7-29, faux window bays with art and colored glass, frost- 
ed glass, and quality indirect lighting were used. 
Foundation walls were penetrated to create basement 
window wells to maximize available natural light. In all OR 
(Color Plate 28, Figure 7-15) and procedure rooms, as 
well as behind each recovery bed, back-lit film trans- 
parencies are used to connect patients to nature. Natural 
maple woodwork and furniture add warmth and a soft 
glow. This is a welcome antidote to the "sterile" colorless 
settings typically seen. It also speaks of quality and atten- 
tion to detail. 

Pediatric Recovery. When the FOSC accommodates 
children on a regular basis, a pediatric recovery area 




Figure 7-28. Staff lounge, with natural light from clerestory windows. Note the use of a mirror 
to reflect light. {Architecture: Hope Consulting; Interior design: Jain Malkin Inc.; Photographer: 
John Christian.) 



Individual Components of an FOSC 365 



should be provided that is separate from, but adjacent to, 
adult recovery. Space for a family member must be pro- 
vided near each crib or bed, which means that more area 
per patient may be required than for adult beds. Sound 
control is very important here, as it is unpleasant for 
adults to hear children screaming and crying. 

Pediatric recovery may receive the same interior fin- 
ishes as the adult area, but could have a pediatric wall- 
paper border to make the environment a little less clinical. 
An environment that no doubt delights children and par- 
ents as well is shown in Color Plate 29, Figure 7-16. 

Generally, this area would be monitored by the adult 
recovery nurse station. This can be accomplished by 
using glass walls to enclose each pediatric bed, allowing 
good visibility from the nurse station. 

Recovery Lounge (Stage II) 

As the patient becomes more alert, the staff evaluate his 
or her condition and, as soon as vital signs have stabi- 
lized and nausea (if any) has subsided, the patient would 
walk to the recovery lounge. This room accommodates 
the final stages of recovery in a more comfortable setting, 
where companions may sit with the patient (Figure 7-22). 
When the staff observe that the patient has been stable 
for at least half an hour, discharge instructions will be 
given to patient and family, and the patient will be formal- 
ly discharged. Adequate space is needed to accommo- 
date family, and the second-stage recovery would opti- 
mally be near the family waiting area. 

The recovery lounge, equipped with comfortable reclin- 
er chairs and lounge seating, should be immediately adja- 
cent to postanesthesia recovery. Observation by medical 
staff is still required, but it is more casual. The short dura- 
tion of stay and the use of chairs, rather than beds, allow 
this area to be considerably smaller than postanesthesia 
recovery. The number of chairs depends on individual pro- 
gram requirements. For example, patients undergoing 
ophthalmic surgery with a local anesthetic may proceed 
almost immediately from the OR to a recliner chair in sec- 
ondary recovery. The dressing area and toilets will be 
immediately adjacent to secondary recovery. 



The 2001 edition of the AIA Guidelines requires the 
number of second-stage recovery stations to be one-half 
the minimum required total of first-stage PACU beds. 

There is no restriction on the types of interior finishes 
that may be used in the recovery lounge, other than what 
good sense would mandate with respect to flammability 
and maintenance. Upholstery on recliner chairs must be 
washable. Carpet is an appropriate floorcovering, and 
vinyl works well on the walls. This area can be designed 
like a residential living room, with indirect lighting or table 
lamps. Natural light and views are highly desirable. 



Administration 

An ASC will need private offices for the medical director, 
the director of nursing or the OR supervisor, and the busi- 
ness manager or clinic administrator. The director of nurs- 
ing's office should be adjacent to the surgical core or to 
the recovery room, where he or she can keep an eye on 
operations. Sometimes the office has a one-way glass 
window overlooking the nurse station in the surgical core. 



RECOVERY-CARE CENTERS 

Overnight recovery-care centers that provide extended 
observation following outpatient surgery exist in some 
states. These are defined by FASA as facilities that pro- 
vide postsurgical care of the patient discharged from the 
postanesthesia care unit with a defined length of stay 
based on each state's regulation. According to FASA, the 
first extended postsurgical recovery-care unit in an ambu- 
latory surgery setting was developed in 1984 in Coeur 
d'Alene, Idaho. The FASA 1996 recovery-care survey 
determined that 9.6 percent of surgery centers offer 23- 
hour postsurgical recovery care and 0.05 percent of all 
centers offer 72-hour recovery. Postsurgical recovery 
care represents one of the fastest growing trends of the 
ASC market with facilities existing throughout the United 
States with the exception of 1 5 states. Recovery care is 



366 Ambulatory Surgical Centers 



currently not reimbursed by Medicare but the cost effec- 
tiveness of this option is being evaluated. 



23 Hours and 59 Minutes of Care 

The 2001 edition of the AIA Guidelines notes that, 
although most outpatient procedures do not require an 
overnight stay, some require extended patient observa- 
tion for up to "23 hours and 59 minutes of care," which 
refers to recovery-care centers. The need for facilities for 
sleeping and nutrition services, and a communication 
system enabling patients to summon assistance, must be 
addressed. Also included are adequate waiting areas for 
family, including children and adolescents, adequate pri- 
vacy for meetings between physicians and other profes- 
sionals with the patient's family, and accommodation for 
translators or translation equipment. 



Statistics 

Sixty-eight percent of centers that provide extended post- 
surgical recovery care began offering 23- and/or 24- to 
72-hour stays between 1993 and 1995. Recovery-care 
centers make it possible to perform more advanced and 
highly reimbursed procedures on an outpatient basis. 
According to FASA, the geographical distribution of sur- 
gery centers offering recovery care indicates a more 
favorable regulatory climate in the West. California leads 
the nation with 63 centers, followed by Texas and 
Colorado with 28 and 20 centers, respectively. There are 
currently 23 states that have 23-hour postsurgical recov- 
ery/surgery centers. Six states allow for greater than 24- 
hour stays in the surgery center setting, but they differ in 



exactly how they define and license recovery care. For 
example, in Arizona, the recovery-care concept grew out 
of a home recovery unit used by a surgery center. 
Eventually, the state passed legislation providing for a 
separate recovery-care license that enabled surgery cen- 
ters to keep patients up to 72 hours. In Colorado, howev- 
er, surgery centers may use a convalescence license that 
enables them to keep separate beds for patients who stay 
for indefinite periods. These specific beds may be located 
inside the surgery center. 



TYPES OF PROCEDURES NECESSITATING 
EXTENDED CARE 

Orthopedic procedures constitute the largest percentage 
of recovery stays with 35.9 percent of all patients. Plastic 
surgery and gynecology follow with 25.4 percent and 1 6.6 
percent, respectively, according to FASA. Among the 
more common procedures that constitute extended 
recovery are anterior cruciate ligament repair, laparas- 
copic vaginal hysterectomies, laparascopic cholecystec- 
tomies, abdominoplasty, and total facelifts. 



SUMMARY 

There are a number of models for designing ambulatory 
surgical centers. Each meets the goals of a specific pro- 
gram, and the final design of the facility is influenced by 
the available space, the shape of the building, the budget, 
and the personalities of the decision-makers. Success, 
however, can only be achieved by meeting the universal 
goals of ambulatory surgery: low cost, convenience for 
patients and physicians, and a high degree of safety. 



Summary 367 



CHAPTER 8 

Sports Medicine 



OVERVIEW 

Sports medicine may be practiced from a sideline bench, a 
storefront therapist's office, or a multimillion-dollar facility 
employing highly sophisticated techniques appropriate for 
highly paid professional athletes. Programs for these facili- 
ties vary widely depending on the location of the facility, the 
client or patient population it serves, the treatment philoso- 
phy of those who have set up the practice, and the medical 
background or skills of those individuals. In spite of these 
disparate considerations, many issues and concerns are 
germane to all sports medicine facilities, large or small. 

Sports medicine is a practice that focuses on the phys- 
iological health of athletes — professional, amateur, and 
recreational — and the problems and injuries athletes 
encounter. The medical practice most closely allied with 
sports medicine is orthopedics, and the medical director 
of these facilities is often an orthopedic surgeon. Physical 
therapy and fitness training are the other two disciplines 
integrated into this practice. Sports medicine endeavors 
to achieve four goals: 

1 . Maintenance of health and physiological function 

2. Improvement of performance 

3. Prevention of injuries through training and education 

4. Treatment and rehabilitation from injuries 

These goals are not unique to sports medicine, but the 
approach to achieving them may be. In the wake of ever- 
increasing investments in professional and collegiate 
sports and with technological advances in medical treat- 
ment capabilities, practitioners have developed tech- 
niques to allow athletes to recover from injuries more 



quickly and successfully. Treatment has gradually become 
more aggressive, and it is applied in a wholly integrated 
manner, taking into consideration the person's entire 
range of activities in relation to his or her strengths and 
deficits in body structure, musculature, and overall fit- 
ness. The objective is to transfer the responsibility and 
motivation for success to the athlete rather than to allow 
the person to be a passive recipient of treatment. 

The success of these techniques has created public 
demand for access to testing, training, and treatment from 
sports medicine specialists. Practitioners have responded to 
this increasing demand by creating environments that offer 
servicessuitedtotheneedsofawidecross section of the pub- 
lic. A sports medicine facility may combine any number of 
services, including physical therapy, nutritional counseling, 
deep-tissue massage therapy, biomechanical analysis, and 
even prosthetic or reconstructive orthopedic surgery. 

Marketing Plan 

A sports medicine facility's marketing plan will have a direct 
effect on site selection and design. Location near a medical 
complex or hospital is very common for a source of patient 
referrals. Choice of facility, such as an existing space or a 
new building designed to suit, would be determined by the 
availability and flexibility of space and the complexity of the 
service program. Architectural detailing within the facility 
and interior design will be directly related to the desired pub- 
lic image. 

User Mix 

A sports medicine center's users are at any given time asso- 
ciated with one particular function of the center, be it physical 



368 



therapy, fitness training, testing, or medical treatment. The 
client's activity may change from time to time from one 
function to another, such as from physical therapy to fit- 
ness, but normally users are focused on one major activi- 
ty at a time. Thus, the same facility must accommodate a 
variety of needs simultaneously. As an example, a physi- 
cal therapist rehabilitating a patient from an injury must be 
situated so as not to have difficulty communicating with 
the patient due to loud machine noise from the hydrother- 
apy area or disco music drifting in from the aerobics class 
around the corner. Each group of users expects to be 
treated with dignity and consideration, and designers must 
be aware and respond to these needs. 

Providers of these services expect the facility itself — 
its physical layout — to support the goals they establish. 
The facility can do that successfully only if the designers 
clearly understand the practice program and if they meet 
users' expectations for a convenient, comfortable, and 
attractive environment. 



Convenient Access 

A center that is conveniently located, visible from the 
street, and easily accessible from the parking area will 
both enhance its marketing plan objectives and meet 
users' expectations for convenience. A physical therapy 
patient, who faces an intensive six- or eight-week course 
of treatment, may be discouraged by difficult access or 
parking that involves too long a walk to the building 
entrance. These facilities can attract very high volumes of 
users especially if they also sell memberships to the fit- 
ness gym and pool. 



Internal Layout — Need for Visibility 

In physical therapy, fitness, and medical treatment, visi- 
bility by staff is essential for safety and efficiency. In the 
physical therapy area, therapists may work with several 
patients, alternating from one to another. They may be 
applying a muscle stimulator to one person, cervical 



traction to another, setting up a patient on a Cybex™ 
machine, and placing another one in a hydrotherapy 
whirlpool. Each of these patients, once set up, needs no 
further assistance until the 10- to 20-minute cycle has 
ended. Therapists are constantly circulating among 
patients in an open-plan area set up with physical ther- 
apy tables, exercise bikes, large mat tables, and private 
physical therapy rooms or cubicles partitioned with a 
curtain (Figure 8-1). 

In addition to circulating among patients, therapists 
often return to a central charting desk to record events on 
each patient's record. Visibility is essential to controlling 
these activities. Therapists also must be able to watch the 
entry area to greet new patients who have arrived, and 
keep an eye on the hydrotherapy area, which is general- 
ly a separate room positioned so that visibility can be 
maintained. The reader is referred to Chapter 9 for a more 
detailed discussion of physical therapy facilities. 

The fitness area should be entirely open, so that staff 
can monitor use of equipment and weights and so that 
socializing can take place if users desire (Figure 8-2). An 
open plan enables exercise equipment to be arranged effi- 
ciently. It is important to have mirrors on any walls in the 
exercise area that do not contain wall-mounted equipment. 
Mirrors are not for vanity or for the purpose of expanding 
the room visually; they allow people using weight training 
equipment to make corrections in their form. 

If there is a medical practice associated with the facility, 
the area would be partitioned into examination or treat- 
ment rooms, private offices or consultation rooms, a minor 
surgery room, and a nurse station, which should be locat- 
ed so as to command surveillance over all treatment 
areas. The reader is referred to other sections of this book 
for a discussion of efficient layout and requirements of 
orthopedic suites, physical therapy units, and family prac- 
tice suites. 

A pool and spa, if provided, could be either indoors or 
outdoors, depending on the locale's climate. The pool and 
spa generally command a high visual profile from an 
image-building standpoint (Color Plate 30, Figure 8-3), 
and they should be adjacent to the fitness area and lock- 
er/shower facilities. 



Overview 369 




CENTER FO R SPORTS MEDICINE, SAN DIEGO, CA. 

9555 SF 



Figure 8-1. Space plan for sports medicine, 9555 square feet. (Design: Jain Malkin Inc.) 



370 Sports Medicine 








/ 




Figure 8-2. Fitness/therapy gym. (Photo courtesy: Bert Moran, Montana Athletic Club Missoula, MT; Photographer: R. 
Mark Bryant.) 



The aerobics area can be separated completely, need- 
ing no direct visibility from staff other than the instructor 
conducting the session. Visual separation will avoid user 
self-consciousness caused by onlookers. The aerobics 
floor should be well cushioned. There are specific prod- 
ucts designed for this purpose, but success can also be 
achieved with a very dense, thick foam rubber pad under 
an 88 ounce per square yard faceweight cut pile carpet. 
The pile need not be high, but must be dense. 



Lockers and showers (Figures 8-4 and 8-5) will be 
used mostly by fitness and pool patrons, but should be 
convenient to other areas as well. These should be di- 
rectly accessible from the lobby area to avoid unnec- 
essary traffic through other activity areas. 

The business office and reception desk need not nec- 
essarily be combined (Figure 8-6). As the reception area 
is so hectic, it is advisable to locate administrative and 
bookkeeping offices in a quieter area. Medical charts must 



Overview 371 



inn 



ffijV^ 





Figure 8-4. Attractive locker rooms are an amenity appreciated by patrons. (Photo courtesy: Bert Moran, 
Montana Athletic Club Missoula, MT; Photographer: R. Mark Bryant.) 




Figure 8-5. Space-saving lockers are designed to provide space to hang a suit. 
(Photo courtesy: Ideal Products, Ontario, CA.) 



372 Sports Medicine 



be close to reception, but will still need to be accessible to 
the bookkeeping office for billing. In this or any medical 
practice, however, staffing does benefit from one person's 
ability to cover another's station if an absence is required. 
Depending on the size of the facility, there may be a need 
for anywhere from 6 to 12 seats in the reception area for 
those awaiting a physical therapy appointment, for a fami- 
ly member who accompanied a physical therapy patient, 
or for someone waiting for a friend, although those who 
plan to use the pool or work out in the gym generally go 
immediately to the locker room and change clothes. 



Noise 

Several functions cause considerable noise and should be 
separated by distance or mass (walls) without unduly 
restricting visual access where needed. Hydrotherapy 
generates some noise. This area may be separated by 
partially glazed partitions to reduce noise transmission to 
the adjacent physical therapy area. Jacuzzi pump noises 
can be reduced by surrounding pumps with an isolation 
closet. 

The aerobics area should be fully separated by well- 
insulated partitions that run above the finished ceiling, 
since exercisers usually enjoy feeling the beat of the 
music. If the facility is not on the first floor, the designer 
must consider the effect of the aerobics activity on the 
tenants immediately below. The vibration caused by 
jumping and extremely loud music can be unbearable. 



Aesthetics 

The aesthetic character of a sports medicine facility 
depends on the marketing philosophy, target population, 
locale, and budget. A facility that draws patients from with- 
in a controlled environment, such as member-physicians, 
contracted service to sports teams or corporate clients, or 
from referrals within a tightly knit medical office environ- 
ment, would not generally need to invest in a high-profile 
design or use expensive materials to be successful. 




Figure 8-6. Elevator lobby/reception desk. {Design: Jain Malkin Inc.; Photographer: 
Robinson/Ward.) 



Overview 373 



On the other hand, a facility that concentrates on pro- 
viding highly specialized services, which would draw 
from outside the immediate geographic area, or one that 
emphasizes memberships or establishes an exclusive 
character would be more likely to require an image- 
setting design treatment. Health clubs, for example, 
depend entirely on membership sales, and image is very 
important to their marketing effort. Generally, the higher 
the membership fee, the more elaborate the design 
treatment. 



Wet Areas 

Areas within the suite where significant moisture or wet 
activity is present should be carefully considered for mois- 
ture control, cross traffic, and noise. Obvious areas where 
moisture is present are spa areas, hydrotherapy, shower 
rooms, and steam rooms. Not so obvious, but significant, 
are the fitness gym and aerobics room, where high con- 
centrations of vapor will occur due to heavy exertion and 
breathing. Without adequate ventilation, greater than 
needed for normal use, the area will seem "stuffy," and 
mildew odors are likely to occur over a period of time in 
carpets and in areas where cleaning is difficult. 

With the exception of hydrotherapy, wet areas should 
be adjacent to one another or be connected by paths of 
moisture-resistant, slip-resistant flooring. Wet bodies or 
bare feet should not cross carpeting or areas of nonrelat- 
ed activity. An outdoor pool may not be immediately adja- 
cent to the locker/shower rooms, but a path of nonskid 
ceramic tile or slip-resistant rubber flooring can connect 
them and provide spatial definition between areas of dif- 
ferent functions without wall separations (Figure 8-1). 

Users of hydrotherapy usually are dry and dressed 
before leaving that area, so isolation may not be a prob- 
lem. This must be evaluated on an individual basis to 
ensure proper adjacencies and traffic flow. 

All wet areas, including locker and dressing rooms 
adjacent to showers, toilet rooms, spa, and hydrotherapy, 
should be supplied with floor drains. A slight, almost 
imperceptible slope of Y e inch per foot toward strategical- 



ly located floor drains may prevent a broken pipe or stuck 
valve from flooding carpet in adjacent areas. 

Shower and steam rooms should have threshold water 
stops or dams of 1 / 2 -inch maximum height (which must be 
beveled, maximum slope not to exceed 45 degrees) on 
the wet side of the entry, with a floor slope that directs 
water away from the entry. Some shower or steam room 
doors have water troughs at the bottom to prevent water 
from dripping off the door. This water must be delivered 
somewhere and usually winds up at the hinged edge, 
where floor slope is very difficult to control. At this point, 
water will go everywhere, including to the dry side, getting 
trampled into public areas by outgoing feet. One must pay 
special attention to wet floors. 

Rooms housing steam equipment should be well 
drained and ventilated, since steam generators create 
heat and present a hazard of leaking. Ventilation of these 
same areas should be sized to prevent heat and moisture 
buildup. 



Linen Storage 

A designer must be aware of the copious amounts of 
linen used in the daily routine of a sports medicine fa- 
cility. Clean and soiled towels must be accommodated in 
locker rooms (Figure 8-7), as well as the hydrotherapy 
area. The physical therapy area uses linen sheets on the 
tables, pillowcases, and towels. All of this linen must be 
delivered, stored before and after use, and later picked 
up by the linen service. The designer must be sure to 
provide adequate storage space for linen, plus addition- 
al ventilation to keep that which is soiled and damp from 
becoming a nuisance. However, ventilation alone cannot 
overcome an environment that is not kept clean and 
orderly with soiled linen stowed in the proper location. 



Interior Finishes 

The floor surface in wet areas should be slip resistant and 
consistent in texture. The user should not be challenged 



374 Sports Medicine 



with changing from one material to another, because he 
or she will not be concentrating on the difference. The 
change could provide a hazardous surprise. 

For wet areas, ceramic tile is the most favored flooring 
for design application, durability, and surface texture. 
However, contrary to public perception, ceramic tile is not 
always easy to clean. Light-colored grout is almost impos- 
sible to keep clean. The larger the tile, the fewer the grout 
joints. Sheet vinyl is an option of compromise to be used 
in damp areas when budget is a consideration. In 
hydrotherapy, sheet vinyl is quite suitable, preferably with 
a self-coved base. The designer should note whether 
heavy portable tanks will be used. They could compress 
and destroy a flooring material not designed for heavy 
loads. Vinyl composition tile, because of its many seams, 
is undesirable in high-moisture areas. 

Vinyl wallcovering is ideal in a sports medicine facility 
because it offers great variety in texture as well as ease 
of cleaning. If paint is used, it must be semigloss or 
eggshell enamel, fully washable. Painted wallgraphics 
can be especially appealing in this type of facility. The 
reader is referred to Color Plate 31 , Figures 8-8 and 8-9. 



Lighting 

Treatment areas within the facility normally require broad- 
ly distributed lighting of 30 to 50 footcandles. Under ideal 
conditions, the physical therapy area would have indirect 
or ambient lighting. Fixtures might be suspended from the 
ceiling, with the light shining on and bouncing off the ceil- 
ing, creating an overall high level of diffused illumination 
without casting glare in the eyes of patients lying on phys- 
ical therapy tables. In the hydrotherapy area, fitness gym, 
and aerobics room, on the other hand, the standard 2-X4- 
foot fluorescent troffer with a parabolic low-brightness lens 
would be appropriate. The reception area, lobby, or corri- 
dors might benefit from accent lighting focusing on wall- 
graphics, special artwork, or educational exhibits. Other 
chapters of this book provide detailed information on light- 
ing medical spaces such as exam rooms, minor surgery, 
and nurse stations. Specifically, refer to Chapter 13. 




Figure 8-7. Clean and soiled linen storage, in locker room. (Design: Jain 
Malkin Inc.; Photographer: Robinson ANard.) 



CASE STUDIES 

Several examples of sports medicine facilities serve as 
case studies to illustrate the concepts outlined above. 
Each illustrates a different approach to the practice of 
sports medicine. These facilities are clear reflections of 
their individual goals. 



Case Studies 375 



San Diego Sports Medicine Center: 
San Diego, California 

The San Diego Sports Medicine Center has built its prac- 
tice on high volume and a well-developed general referral 
system. Located near a 214-bed hospital owned by Tenet 
Health System, it occupies a ground floor location in one 
of a group of medical office buildings. It is surrounded by 
parking and has immediate access from a major freeway. 

This 1 1 ,000-square-foot facility is operated by a 
group of osteopathic physicians with offices immediately 
adjacent to the center. These internal referrals, as well 
as those from practitioners in adjacent medical office 
buildings, contribute to the volume of this facility. In addi- 
tion, contracts with local schools (athletic programs), 
municipalities, and corporations provide the largest 
source of referrals for both physical therapy and fitness 
programs. Of the four case studies, this facility most 
actively markets the fitness and testing program to a 
wide cross section of the public. As family practitioners, 
the osteopathic physicians encourage outside special- 
ists' referrals for physical therapy relatively free of com- 
petitive conditions. 

The center's programs focus on wellness — maximiz- 
ing one's level of physical fitness and minimizing individ- 
ual health risk factors. This involves assessment of one's 
fitness, education about wellness, and lifestyle evalua- 
tion. The center also offers worksite evaluation to employ- 
ers, incorporating site walk-throughs to assess high-risk 
opportunities for injury. 

Features include a 5500-square-foot physical fitness 
gym, separate aerobics room, physical therapy treatment 
area, and a four-lane lap pool, all contained within a large 
square surrounding a central locker and spa area. From 
the entry, one has immediate access to either the medical 
offices or the sports center administration area, through 
which one must pass to reach the locker rooms. Across 
the parking lot is a one-half-mile winding running track. 

The 4000-square-foot medical office accommodates a 
staff of 10 physicians and clinicians, including radiology 
and a physiology testing lab. This area functions inde- 
pendently of the sports center. 



The central location of the locker/spa area allows con- 
venient access to other areas. Access control is easily main- 
tained by staff in the business/administration area. Access 
to the track is located outside the immediate control of the 
center. The track is used frequently by staff from nearby 
medical offices, and this relationship facilitates outside use 
without unnecessary traffic in the sports center lobby. 

The design character is low key and simple. The center 
prefers to project an understated image that allows the 
facility to remain low profile compared to the high-profile 
service provided. Since clients and patients represent a 
wide cross section of the population through referrals 
from a variety of sources, a straightforward unimposing 
appearance was considered most appropriate. 



Center for Sports Medicine and Orthopedics: 
Phoenix, Arizona 

The second case study incorporates many of the basic 
elements of other sports medicine facilities, but it is 
unique in that it is virtually self-sufficient, relying very lit- 
tle on outside physician referrals or recreational member- 
ships to support it. The Center for Sports Medicine and 
Orthopedics is a $3 million (1985 dollars, when built), 
40,000-square-foot medical treatment and diagnostic 
center that sits on a tiny site originally in the middle of a 
major metropolitan hospital campus (Figure 8-10). The 
freestanding building was raised one story to provide 
parking and to provide shelter for entry during periods of 
inclement weather. When it opened in February 1985, it 
won a Facility of Merit award in 1985 from Athletic 
Business magazine. 

The center was the creation of three Phoenix orthope- 
dic surgeons and a sports medicine specialist who, 
together, were team physicians to 18 professional and 
amateur sports organizations. 

This facility provides contract services to local profes- 
sional athletes and purposely integrates amateur and 
recreational athletes in the same treatment program. 
From a marketing standpoint, being able to converse with 
professional athletes during rehabilitation is a powerful 



376 Sports Medicine 




Figure 8-10. Center for Sports Medicine and Orthopedics, Phoenix, AZ. (Architecture: Devenney Group, Ltd., Phoenix, AZ; Photographer: Michael Much.) 



attraction. The physical therapy program and fitness gym 
are designed to operate directly in conjunction with treat- 
ment and diagnostic programs. The 4000-square-foot 
physical therapy department is owned and operated by 
HealthSouth. All together, medical treatment, diagnostic 
testing, the physical therapy program, and the fitness 
area generate enough referrals to one another to make 
the center economically self-sufficient, relying little on 
outside physician referrals or recreational memberships 
in the gym. It should be noted that the Stark legislation 
enacted a few years ago to control physician referrals to 
ancillary services owned by those physicians changed 



practice patterns, resulting in the physical therapy busi- 
ness being owned by HealthSouth, a large rehabilitation 
company, which, in fact, now owns the building. 

It is interesting to see the changes that have occurred 
in this enterprise over the past 1 years, between the sec- 
ond and third editions of this book, as they are reflective of 
changes and stresses in the healthcare industry in gener- 
al. The hospital and its campus went out of business and 
have been replaced by a grocery store. The last of the 
orthopedic surgeon founding fathers (all osteopaths) 
retired in 1999. The mix of providers has changed to 
include 5.5 osteopathic family practice physicians (all cer- 



Case Studies 377 




Figure 8-11. Space plan, Center for Sports Medicine and Orthopedics, Phoenix, AZ. (Architecture: Devenney 
Group, Ltd., Phoenix, AZ.) 



tified in both sports medicine and family practice) and just 
one orthopedic surgeon. They are the team physicians for 
the Phoenix Suns, Phoenix Coyotes, Arizona Diamond- 
backs, and Phoenix Mercury (WNBA), as well as some 
junior colleges, high schools, gymnastics clubs, and many 
other sports groups, including the Seattle Mariners and 
Los Angeles Dodgers during spring training. 

The center originally marketed to local employers a 
successful work-hardening program called the "Industrial 
Athlete," but has since replaced it with a program of exec- 
utive wellness/physical assessment offered to individuals 
as well as employees of very large organizations with 
which it has contracted. 

The overriding concept of the facility is that it is a med- 
ical facility first and foremost, as opposed to a member- 
ship fitness facility. The image is tailored to a center spe- 
cializing in sports medicine treatment. As a result, an 
ever-increasing number of patients have been attracted 
to the facility from beyond the local service area. 

As the facility was built to suit and freestanding, it was 
possible to express the program's concepts through the 
architecture, sculpting various activities around the 
1 0,000-square-foot biomechanics pavilion. 

What appears to be an open-air park (Figure 8-10) 
located above the covered parking area is, in fact, a 
sophisticated training field that allows athletes' motions to 
be captured on high-speed video so that experts can 
observe defects in technique that might lead to injuries. A 
basketball court, pitcher's mound, running track, and vol- 
leyball court are included, each with the type of flooring 
material typically found in a professional setting. 

The entry and reception area form the facility's center 
to allow direct access to all areas, similar to the previous 
case study (Figure 8-11). The medical treatment center, 
fitness gym, administrative offices, physical therapy area, 
lockers, and swimming pool radiate around the reception 
station for visual control and convenient access. 

Directly beyond the fitness area is the conference cen- 
ter, which includes a large auditorium, classrooms, sepa- 
rate restroom facilities, and entrance from the parking 
area below. 



378 Sports Medicine 



Athletic activity is the theme of an extensive collection 
of artwork displayed throughout the building, including a 
prominent, life-sized bronze sculpture of a gymnast. 
Interior finishes and furnishings are color-coordinated 
right down to the staff uniforms, to emphasize the disci- 
pline devoted to all details of the facility, reflecting consis- 
tency between the physical setting and manner of treat- 
ment. This sports medicine facility displays the design 
continuity that can be achieved when all objectives and 
goals are aligned in one program and expressed between 
the client and designers as an integrated whole. 



The Center for Sports Medicine: 
San Diego, California 

The third case study is an example of a facility that has 
become the centerpiece of an older, well-established med- 
ical office complex. The site consists of five sizable medical 
office buildings, the largest of which is a 90,000-square- 
foot, high-profile building with glass elevators. Located on 
the lower or plaza level of this building, just across the 
street, are a regional children's hospital and a 415-bed 
community hospital with a tertiary program in cardiac sur- 
gery. The site is accessed by two converging freeways. 

The 9500-square-foot facility includes a physical thera- 
py program, fitness gym, aerobics room, administrative 
and business offices, locker rooms, an NCAA-sized lap 
pool and large outdoor spa (see Figure 8-1). 

The physical therapy area serves patients referred by 
physicians in adjacent medical buildings as well as by 
others off site. The fitness gym is used by physicians and 
staff of nearby medical offices who participate through 
private memberships. Some physicians offer employees 
memberships to the facility as an employment benefit. 

This sports medicine facility was developed partly as a 
marketing feature to attract physicians to the medical 
buildings, to generate revenue for the physicians and oth- 
ers who own stock in the corporation, and to provide con- 
venient treatment for patients at the same location as 
their physicians' offices. Design image was established as 
a high priority. Intricate ceramic tile designs were created 




Figure 8-12. Aerobics area. (Design: Jain Malkin Inc.; Photographer: 
Robinson/Ward.) 



for locker rooms and the path connecting the locker 
rooms to the pool (see Figure 8-6). Colorful soffitted ceil- 
ings, wallgraphics, and inset carpet borders were used to 
create an upbeat, stylish ambience. 

Decorative lighting is used in the reception lobby. From 
the lobby, all other areas of the facility are directly acces- 
sible, arranged somewhat like spokes around a hub 
(Figure 8-9). The locker rooms, physical therapy area, 
administration offices, and fitness gym are accessible 
without any cross traffic. The aerobics area (Figure 8-12) 
is open and accessible from both the gym and the phys- 
ical therapy area for overflow needs as one or the other 



Case Studies 379 



becomes more or less busy throughout the day. 
Occasionally, there is some interference between the aer- 
obics use and physical therapy due to loud music being 
played during the aerobics sessions. Early in the pro- 
gramming, however, it was determined that the availabili- 
ty of space to physical therapy would justify the occasion- 
al periods of possible conflict in the early morning and 
late afternoon, when therapy activity is light. The staff 
report that the tradeoff has proven worthwhile. 

Through a team effort of the center's staff, the build- 
ing owners, and local building officials, the designers 
were able to transform some rather unusual and chal- 
lenging existing building conditions into assets. The re- 
sultant design was functional, flexible, and affordable, 
allowing the center to expand by 25 percent without 
remodeling existing features or suspending ongoing 
activities. 




Figure 8-13. Montana Athletic Club, Missoula, MT. (Photo courtesy: William Merci, Kessler, Merci and Associates, 
Chicago, IL; Photographer: Greg Merci.) 



Montana Athletic Club — Missoula: 

Missoula, Montana 

Montana Orthopedic Physical Therapy: 

Missoula, Montana 

Appearing to grow out of the earth, nestled in the moun- 
tains (Figure 8-13), this $4.6 million (cost in 1986, when 
built), high-tech facility has a threefold mission. It func- 
tions as a health club, it serves as a physical therapy clin- 
ic for the rehabilitation of sports injuries, and it supplies 
certified athletic trainers, on contract, to local schools and 
recreational sports teams. 

The facility markets corporate memberships to employ- 
ers as a perk for employees. A new Cardiac Phase III and 
Phase IV rehabilitation program addresses the large sen- 
ior citizen population the center serves. Owner Bert 
Moran states that currently (year 2000) managed care 
accounts for 50 percent of the facility's business, which 
has eroded profits. Prior to managed care, 40 percent of 
gross revenue derived from physical therapy services; 
currently, it is only 20 percent and 80 percent of the rev- 
enue is from the athletic club, which is doing a brisk busi- 
ness. To assure greater financial viability, plans for a spa 
are under way. 

Owned by a woman with a degree in finance, the facil- 
ity employs an exercise physiologist as well as physical 
therapists and certified trainers. The indoor competition- 
sized track (Figure 8-14) was an important component of 
the design program, biomechanically designed to reduce 
the runner's potential for injury and to increase speed by 
as much as 3 percent. Windows offer runners a 
panoramic view of the valley. The 1 500-square-foot phys- 
ical therapy area includes a separate hydrotherapy room 
(Figure 8-15). Large locker rooms (see Figure 8-4), a fit- 
ness gym, basketball court, pool, snack bar/lounge, pro 
shop, conference room, classrooms, and administrative 
offices are arranged with great care in a layout that is 
both functional and aesthetically appealing (Figures 8- 
16, 8-17, and 8-18). Architecturally, this facility merits 
high marks for its high-tech design and careful detailing 
not often found in facilities of this type. It is easy to 



380 Sports Medicine 



Figure 8-14. Indoor track, biomechani- 
cally designed to reduce runner's 
potential for injury and to increase 
speed. Windows offer panoramic view 
of valley. (Photo courtesy: Bert Moran, 
Montana Athletic Club Missoula, MT; 
Photographer: R. Mark Bryant.) 



Figure 8-15. Hydrotherapy room. Note that whirlpools have been built in 
(Photo courtesy: William Merci, Kessler, Merci and Associates, Chicago, 
IL; Photographer: Greg Merci.) 



see why it was named a "Facility of Merit" by Athletic 
Business in 1987. 

One of the innovations of the design involves the 
mechanical system which integrates, through a highly 
sophisticated computer, all the HVAC components of the 
building in order to achieve energy conservation. The 
pool, for example, serves as a heat dump for the rest of 
the building. 




Case Studies 381 




Figure 8-16. Main floor, Montana Athletic Club, Missoula, MT. (Design: William Merci, Kessler, Merci and Associates, Chicago, IL.) 



382 Sports Medicine 



■t 4 ' ' ' ' ' T *"*"*' 




-- ■ - - - 



•^— 1 ^^ «|^.^|_^^_^^L^ 



~-vf-~— 



i i t --^- 



Figure 8-17. Second floor, Montana Athletic Club, Missoula, MT. (Design: William Merci, Kessler, Merci and Associates, Chicago, IL.) 

Author's note: Track has been reduced to two lanes because the turns were too steep, resulting in injuries. It is noted for being the fastest and largest indoor track in the Northwest. 
Also, the offices have been replaced by a cardiac rehab space. 



Case Studies 383 



longitudinal section 




transverse section 



Figure 8-18. Sections through building, Montana Athletic Club, Missoula, MT. (Design: William Merci, Kessler, Merci and Associates, Chicago, IL.) 



384 Sports Medicine 



CHAPTER 9 

Paramedical Suites 



Two types of paramedical suites, physical therapy and 
pharmacy, will be discussed in this chapter. 



PHYSICAL THERAPY 

Patients requiring physical therapy may need rehabilita- 
tion following surgery, stroke, trauma, or a work-related 
injury ranging from carpal tunnel syndrome to cervical 
problems associated with lifting heavy items or frequent 
twisting or bending movements. Usually referred by a 
physician, patients arrive for an initial evaluation, followed 
by a series of visits that may range from one to three times 
per week. For each patient, a routine is established that 
quickly becomes familiar. Some patients have to warm up 
by riding an exercise bike for 10 minutes prior to starting 
therapy and, after checking in with the receptionist, they 
proceed to the gym and set themselves up without the 
therapist greeting them. First-time visitors will wait in the 
reception room until called by the therapist. 

Patients are usually asked to wear shorts or other gar- 
ments that expose the injured limb, which means that the 
therapist can often treat them in an open, nonprivate 
area, working on a massage table, bending or massaging 
a limb to achieve better flexibility or range of motion, per- 
haps applying electrical stimulation to a muscle and, at 
the end of the session, applying ice to reduce swelling. 

The gym floor must have sufficient open space to be 
used as a gait lane to visualize patients' ambulation and 
also to provide room for patients to exercise with elastic 
ankle bands or straps or other devices. A quieter, or less 
active, part of the gym should have one or more small rec- 



tangular tables for a hand therapist who sits across from 
the patient. A nearby work area will provide space to fabri- 
cate braces to immobilize the hand. This requires storage 
for the Velcro® straps and other splint materials as well as 
a small device to heat the material so it can be molded. 

Visibility by staff is essential for safety and efficiency in 
the physical therapy area. Therapists may work with sev- 
eral patients, alternating between them. They may be 
applying an electrical muscle stimulator to one person for 
10 minutes, cervical traction to another for 20 minutes, 
setting up a patient on a Cybex machine, and placing 
another in a hydrotherapy tank for 20 minutes. Once set 
up, each of these patients needs no further assistance 
until the 10- to 20-minute cycle has ended. Therapists 
continually circulate among patients in an open plan 
arrangement set up with physical therapy tables, exercise 
bikes and other equipment, large mat tables, gait lanes, 
and private physical therapy rooms or cubicles partitioned 
by a curtain. The many activities going on simultaneous- 
ly can make the treatment area very hectic. For this rea- 
son, natural light, ample window area, and views of 
nature are essential to both the therapists' and the 
patients' well-being. The open-plan workstations in 
Figures 9-16 and 9-17 work well. 



Physical Therapy Modalities 

There are eleven basic modalities of physical therapy: 



1 . Hydrotherapy 

2. Heat or cold 



385 




Figure 9-1. Full-body immersion hydrotherapy tank. {Photo courtesy: Jain Malkin Inc.) 

Table 9-1. 

Analysis of Program. 

Physical Therapy 



Waiting Room 




14 x 16 


= 224 


Business Office 




10 x 16 


= 160 


Tech Work Area/Charting 




8 x 12 


= 96 


Gym 




20 X36 


= 720 


Whirlpool Rooms 


3@ 


6X8 


= 144 


Treatment Rooms 


5@ 


8X9 


= 360 


Toilet 




7X9 


= 63 


Laundry 




10 x 12 


= 120 


Private Office or Staff Lounge 




10 x 12 


= 120 


Storage 




8X10 


= 80 


Subtotal 






2087 ft 2 


20% Circulation 






417 


Total 






2504 ft 2 



3. Massage 

4. Exercise 

5. Ultrasound 

6. Traction 

7. Electrical stimulation 

8. Transcutaneous electrical nerve stimulation (TENS) 

9. Iontophoresis 

10. Continuous passive motion 

11. Mobilization 

Hydrotherapy 

Hydrotherapy involves immersion of a limb or, at times, 
even the entire body, in water. The tank may be a portable 
whirlpool or a full-body Hubbard tank (Figure 9-1). The 
latter is more apt to be found in a hospital physical medi- 
cine department. Mobile whirlpool tanks (Figure 9-2) may 
be filled and drained with a hose. The patient sits in a high 
chair such as that shown in Figure 9-4 and swings a leg 
over into the whirlpool. The full-body whirlpool in Figure 
9-3 requires permanent water and waste connections. 
Since large amounts of hot water release a lot of steam, 
the walls of rooms with large tanks should have at least a 
5-foot-high ceramic tile wainscot with commercial vinyl 
wallcovering above. The preferable flooring material is 
ceramic tile or else commercial-quality sheet vinyl. 

Occasionally, physical therapy suites have built-in 
whirlpools, but most will have a couple of small portable 
tanks suitable for an arm or a leg. Floor sinks must be pro- 
vided for portable tanks, which have to be drained and 
filled for each patient. A hose connection to a nearby tap 
may suffice for filling the tank. Whirlpool rooms or enclo- 
sures are usually 6X8 feet in size and may be closed off on 
the open side by a cubicle drape. Depending on the loca- 
tion of walls and circulation between hydrotherapy tanks, 
in order to accommodate ADA access, larger spaces may 
be needed. 



386 Paramedical Suites 






Figure 9-2. Mobile arm, foot, and knee whirlpool. {Photo 
courtesy: Ferno-Washington, Inc., Wilmington, OH.) 



Figure 9-3. Full-body stationary whirlpool. {Photo courtesy: Ferno- 
Washington, Inc., Wilmington, OH.) 



Figure 9-4. Mobile adjustable high chair. 
{Photo courtesy: Ferno-Washington, Inc., 
Wilmington, OH.) 



There are several ways of designing the hydrotherapy 
area. 

1 . A large hydrotherapy room can be designed to 
accommodate several portable whirlpools, plus the 
Hydrocollator® units (steam packs), the cold pack 
unit, and the ice machine. 

2. Individual privacy cubicles can be created as in 
Figure 9-12, each having a sloped ceramic tile floor 
with drain and plumbed for hot and cold water to fill 
the mobile whirlpool tank. 

3. Fiberglas or stainless steel mobile whirlpool tanks 
may be enclosed to appear built-in as in Figure 8-15. 
They may be placed in either a large open room or 
individual privacy cubicles. 



If whirlpool tanks are placed in privacy cubicles, the walls of 
these enclosures should have a 3- or 4-foot-high wainscot 
of ceramic tile, and the wall above the tile must have a 
waterproof enamel finish or commercial vinyl wallcovering. 

Heat or Cold 

Heat is produced by a variety of methods, ranging from a 
simple electric heating pad to hot steam packs to soaking 
the affected part of the body in hot water or placing it in 
hot paraffin (Figure 9-5). Figure 9-6 shows two models of 
heating units. The unit must be filled with water by a hose 
from a nearby faucet. It plugs into a standard 120-volt ac 
grounded outlet. Figure 9-7 shows what the steam packs 
look like, and Figure 9-8 shows optional terrycloth covers 
for wrapping the steam packs. If these covers are not 



Physical Therapy 387 




Figure 9-5. Mobile arm, hand, and foot bath. {Photo courtesy: Ferno- 
Washington, Inc., Wilmington, OH.) 




Figure 9-6. Hydrocollator (hot pack) units. (Photo courtesy: Chattanooga Group, Inc., Hixson, TN.) 





Figure 9-7. Steam packs. (Photo courtesy: 
Chattanooga Group, Inc., Hixson, TN.) 



Figure 9-8. Terrycloth covers for steam packs. 
(Photo courtesy: Chattanooga Group, Inc., Hixson, 
TN.) 



388 Paramedical Suites 



used, the steam packs must be wrapped in several layers 
of terrycloth towels. 

A good deal of laundry is generated here. Suitable stor- 
age must be provided for clean linen, a large hamper for 
soiled linen, and a drying rack in a ventilated louver-door 
closet for drying wet towels until the linen service picks 
them up. 

Cold is normally produced by cold packs or ice, which 
are applied to the affected part of the body. Figure 9-9 
shows various sizes of chilling units. Figure 9-10 shows 
what the cold pack looks like. These units have the same 
electrical requirements as the steam pack units. Both the 
cold pack and the steam pack units may be positioned 
immediately adjacent to built-in cabinetry in order to pro- 
vide a large countertop area for wrapping steam packs. 
The average height of these units is 33 inches. 

The steam pack and cold pack units, along with an ice 
machine (Figure 9-11), may be located in the hydrothera- 
py room with the portable whirlpools, or it may be located 




Figure 9-10. Cold packs. {Photo courtesy: Chattanooga Group, 
Inc., Hixson, TN.) 





Figure 9-11. Ice dispenser on stand. 
(Photo courtesy: Hoshizaki America, Inc., 
Peachtree City, GA.) 



Figure 9-9. Chilling units. (Photo courtesy: Chattanooga Group, Inc., Hixson, TN.) 



Physical Therapy 389 



63-0" 





















SlAIKS 














PHYSICAL THERAPY 



2646 SF 



Figure 9-12. Space plan for physical therapy, 2646 square feet. (Design: Jain Malkin Inc.) 



390 Paramedical Suites 




Figure 9-13. Physical therapy treatment table. (Photo courtesy: 
Hausmann Industries, Inc., Northvale, NJ.) 



in a separate equipment room, as shown in Figure 9-12. 
This equipment room might also contain a storage area 
for small pieces of portable equipment when not in use, 
such as muscle stimulators, the ultrasound cart, and the 
TENS unit. 

Massage 

Massage is the oldest form of physical therapy. It is gen- 
erally performed in private cubicles, which may be con- 
structed of standard gypsum board partitions on three 
sides with a ceiling-mounted drape on the fourth side 
(Figure 9-12), or treatment cubicles may be contained in 
one large room, each one separated from the others only 
by ceiling-mounted cubicle drapes. In either case, the 
treatment modules need to be approximately 8 feet wide 
by 9 feet long. A physical therapy treatment table (Figure 
9-13) is 27 to 30 inches wide and 78 inches long. It would 
be placed in the center of the room, with space for the 
therapist to access either side of the patient. The room 
may also have a chair, wall mirror, hooks for patient's 
clothing, and a shelf for creams and ointments that may 
be used during the massage. Various types of portable 
equipment, such as a muscle stimulator or ultrasound 
unit, may be wheeled into the cubicles as needed 
(Figures 9-14 and 9-15). 





Figure 9-15. Standard physical therapy mobile equip- 
ment cart. [Photo courtesy: Chattanooga Group, Inc., 
Hixson, TN.) 



Figure 9-14. Ultrasound unit and muscle stimulator, 
Sonicator® 730 and Sys*Stim®, on mobile cart. {Photo 
courtesy: Mettler Electronics Corp., Anaheim, CA.) 



Physical Therapy 391 




Figure 9-16. Open physical therapy treatment area with therapists' charting station in rear. (Design: Jain Malkin Inc.; Photographer: Jain Malkin.) 



Subdued, indirect lighting is optimal for these rooms. 
One would not want to subject the patient to the glare of 
overhead lighting. The interior finishes and color of these 
spaces should be soothing and restful, not stimulating. 

It should be noted that some physical therapists prefer 
that at least 50 percent of the treatment tables be 
arranged in an open area (Figures 9-16 and 9-17) and 
that the therapists' charting and workstations be similarly 
open, with an unobstructed view of the gym floor. A 42- 



inch-high partition with a 34-inch-high work counter on 
the other side meets this goal. 

Exercise 

A good deal of physical therapy involves the use of gym 
equipment. A large exercise room should be provided for 
exercise equipment, some of which is wall mounted and 
some of which stands on the floor. Although windows and 
a nice view make exercising very pleasant, considerable 



392 Paramedical Suites 



109-0" 



■7*- 




STAFF ENTRY 



□ 



THERAPISTS' 

WORK 
STATIONS 




Tl 



T-J 



1^3 



PT 



PT 



PT 



TREATMENT CUBICLES 

— a — b — b_ 



;HP 

PLANTER 



I MAGAZINES 








^^ 






1 


I 


RECEPTIO 




BUSINESS 1 
N OFFICE^J 




ICOPEll 



"G 



13 



HAM) 




1 




D 




a 
a 


i 
i 
i 




IE 


D 


D 


D 









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u 




-7<- 



PHYSICAL THERAPY 



4200 SF 



Figure 9-17. Space plan for physical therapy, 4200 square feet. (Design: Jain Malkin Inc.) 



Physical Therapy 393 




Figure 9-18. Parallel or gait bars. (Photo courtesy: Hausmann Industries, Inc., 
Northvale, NJ.) 



Figure 9-20. Ambulation staircase. (Photo courtesy: Hausmann 
Industries, Inc., Northvale, NJ.) 



Figure 9-19. Cybex exercise bike. (Photo courtesy: 
Cybex International, Inc., Medway, MA.) 




394 Paramedical Suites 



wall space will be required for positioning wall-mounted 
equipment such as stall bars, weights, and pulleys. 

The room may also have gait bars (Figure 9-18), exer- 
cise bicycles (Figure 9-19), barbells, an ambulation stair- 
case (Figure 9-20), pulleys (Figure 9-21), and a shoulder 
wheel (Figure 9-22), as well as other gym equipment and 
mat tables (Figure 9-27). Note that physical therapy facil- 
ities sometimes have very sophisticated electronically 
integrated exercise equipment that can be calibrated to 
measure slight changes in a patient's progress (Figure 



9-17). This equipment is designed to increase strength, 
flexibility, and range of motion and records resistance and 
other measures of muscle function, often printing out a 
chart or graph for the patient's medical record. Cybex and 
Med-X™ are two examples of this equipment. 

Wall-mounted equipment must be located before con- 
struction begins, since the walls will require plywood rein- 
forcement to support the additional weight. The room 
should have a 9-foot ceiling height and large mirrors, 
which must be positioned so that people can see them- 





Figure 9-21. Chest pulley weights. {Photo courtesy: Hausmann 
Industries, Inc., Northvale, NJ.) 



Figure 9-22. Shoulder wheel. {Photo courtesy: Hausmann Industries, 
Inc., Northvale, NJ.) 



Physical Therapy 395 




selves using the equipment. Stylized wallgraphics of peo- 
ple exercising add vitality to the room (Figures 9-23 and 
9-24). Color Plate 31, Figures 8-8 and 8-9, are examples 
of graphic design. Carpet is the preferred flooring for the 
gym and treatment bays. Functionally, it softens the blow 
if weights are dropped and absorbs noise; visually, it soft- 
ens the geometry of the equipment. Carpet should be 
very dense, low pile, directly glued to the slab without a 
pad. Vinyl-backed carpet, commonly used in hospitals, is 
a good choice as it's firm and prevents spills from reach- 
ing the slab. 

Consider the use of indirect lighting in the gym and 
exercise areas. It is especially appropriate when people 
are lying on their backs looking up at the ceiling. The glare 
from standard fluorescent fixtures is unpleasant. Refer to 
Chapter 13 for examples of pendant and recessed fix- 
tures that direct light to the ceiling, from which it reflects, 
to provide ambient illumination. 



Figure 9-23. Physical therapy gym. (Design: Jain Malkin Inc.) 




Figure 9-24. Physical therapy gym. (Design: Jain Malkin Inc.) 



Ultrasound 

Ultrasound involves an acoustic high-frequency vibration 
that is used to produce deep heat in muscle tissues. The 
ultrasound unit is small (see Figure 9-14) and can be 
wheeled on a mobile cart to a room as needed. It requires 
no special accommodation. 

Traction 

Traction can be applied to various parts of the body. The 
procedure removes pressure from the muscles, liga- 
ments, and tendons of the area being treated to allow the 
return of proper nerve flow and blood flow through the 
area, as well as to promote normal joint mobility patterns. 
A traction table is shown in Figure 9-25. The electronic 
control unit is affixed to the end of the table. 

Electrical Stimulation 

Electrical impulses in milliamperages are delivered into 
the muscle to elicit external control of the muscle. 
Ranges of control extend from slight muscle tension to 
complete and extended muscle contraction. Electrical 
stimulation may be used to fatigue a muscle for treating 
spasm, for muscle re-education, to strengthen muscles, 



396 Paramedical Suites 





Figure 9-25. Table used for mobilization adjustments with traction device attached. {Photo 
courtesy: Chattanooga Group, Inc., Hixson, TN.) 



Figure 9-26. TENS unit neurostimulator. (Photo 
courtesy: Empi, Inc., St. Paul, MN.) 



to stimulate debilitated muscles, and for pain manage- 
ment. Figure 9-14 features a neuromuscular stimulator 
on a mobile cart. 

Transcutaneous Electrical Nerve Stimulation 

Transcutaneous Electrical Nerve Stimulation (TENS) is 
the procedure of applying controlled, low-voltage electri- 
cal impulses to the nervous system by passing electrical 
current through the skin via electrodes placed on the skin. 
TENS therapy has been shown to interrupt or break the 
pain cycle, which facilitates control of spasms, inflamma- 
tion, and pain. The TENS unit is shown in Figure 9-26. 

Iontophoresis 

Iontophoresis is the process of driving medication topi- 
cally through the skin by means of an ion transfer device. 
This is a small unit that may be stored in a cabinet. 




Figure 9-27. Exercise mat table. {Photo courtesy: Hausmann Industries, Inc., Northvale, NJ.) 



Physical Therapy 397 



Continuous Passive Motion 

Continuous passive motion (CPM) is a technique for 
rehabilitating a joint or muscle group that has become 
inhibited, weak, tight, or otherwise injured. These devices 
would typically not be used in an outpatient physical ther- 
apy setting but would, rather, be used postsurgical^ to 
keep the limb in motion after a total knee replacement, for 
example. 

Mobilization 

Mobilization is a chiropractic-type manipulative therapy 
that mobilizes vertebral segments and other joints of the 
body to realign them to proper positioning and to restore 
normal joint motion. These procedures are sometimes 
called adjustments. A special segmented, adjustable 
table is used (see Figure 9-25) for these treatments. 



Other Areas 

A physical therapy suite will also contain a business 
office, a waiting room that accommodates wheelchairs 
and people on crutches, toilets that serve the disabled, 
one or more private offices for administration, a staff 
lounge, perhaps a laundry room with washer and dryer, 
convenient storage for clean and dirty linens, and a ther- 
apists' charting station. 

The charting station may be a large circular table with 
four or five chairs on casters for the therapists. It should 
be placed in the large exercise room so that therapists 
may keep an eye on patients while completing paperwork 
and also have a good view of all treatment areas. 

A small men's and women's locker room/bathroom may 
be provided to facilitate patients changing into shorts 
prior to their treatment. 




Figure 9-28. Work-hardening laboratory allows patients to practice industrial skills under the guidance of a therapist. 
{Designer: David Guynes, Phoenix, AZ; Photographer: David Guynes.) 



Work Hardening and Industrial Medicine 

Work hardening is goal-oriented clinical treatment geared 
to return people to the work force in a timely manner fol- 
lowing an injury. Real or simulated job tasks, coupled with 
conditioning, are included in the treatment plan for each 
patient. A series of workstations allows systematic clinical 
evaluation of a patient's functional capacity and 
endurance, postinjury conditioning, and rehabilitation 
needs. The factory or workroom training module would be 
designed and equipped for tasks inherent in industries 
representative of the hospital's service area. Module task 
simulators may include a stud wall simulator, which is an 
open stud wall with predrilled holes at a variety of angles 
and heights permitting plumbing and electrical wiring sim- 
ulations. A bending/range-of-motion simulator is fully 
adjustable for complete range-of-motion exercises. A 
shelf system is designed to evaluate the ability to lift or 
reach, required for certain industrial tasks. Weighted con- 
tainers in assorted sizes and shapes are also provided. 

The work-hardening environment in Figure 9-28 is 
particularly effective because equipment modules are 
placed in a simulated industrial environment where 
appropriate visual cues make the training experience 



398 Paramedical Suites 



more realistic. This concept has been highly regarded by 
employers who are motivated to rehabilitate injured 
workers quickly. As a preventive measure, training new 
employees to use muscles properly for specific tasks 
makes sense. 

Industrial medicine (also called occupational medi- 
cine) practices fall into two broad categories. Both are 
geared to treating work-related injuries. Clinics, the first 
type, triage all types of injuries that might occur in the 
workplace, including lacerations, burns, and spine and 
joint injuries. Patients may avail themselves of these 
services without a prior referral. The other type of indus- 
trial medicine practice, often run by an orthopedic sur- 
geon, signs contracts with large employers to handle 
workers' compensation referrals. Before a patient can be 
treated, the visit must be approved by the claims adjus- 
ter. This is an area where reimbursement is lucrative, 
unlike the situation that exists today in many types of 
medical practices. 



Special Issues 

Structural support for freestanding equipment as well as 
hydrotherapy tanks (if large) must be evaluated with 
respect to floor load. Occasionally, specialized rehab 
equipment has such concentrated loads that the floor 
must be reinforced. Evaluating the final fixed positions of 
each piece of equipment, their individual and combined 
weights, against the structural system of the building 
looking at locations of beams, stairs, and sheer walls, is 
not only practical but essential. 

All electrical outlets must be grounded, and codes 
usually require ground-fault interrupters on whirlpool 
tanks. 



PHARMACY 

This discussion will be limited to pharmacies located in 
medical office buildings. Since the pharmacy's primary 
(and in some cases, total) source of business is the ten- 



ants in the buildings, it is wise not to plan the pharmacy's 
space until the tenants and their respective specialties 
are known. If the medical office building is isolated and 
not adjacent to neighborhood foot traffic, the pharmacy's 
referrals will come exclusively from the medical office 
building. However, if the pharmacy was in business in the 
neighborhood before moving into the new medical build- 
ing, chances are a certain amount of outside business 
will follow the pharmacist to the new location due to loy- 
alty or to prior business arrangements. 

Thus, it is necessary to analyze the source and num- 
ber of prescriptions, both new and refills. Once the tenant 
population is known, the volume of prescriptions can be 
analyzed. A general practitioner or internist will see 25 to 
35 patients per day, and perhaps two-thirds of those 
patients will be given a prescription. Certain specialties 
tend to generate more prescriptions than others. When 
the estimated number of prescriptions (or "scripts") to be 
derived from the tenant population has been determined, 
one must speculate on what percentage of those scripts 
will end up at the building's pharmacy. If physicians in the 
building like the pharmacist, if the pharmacist provides a 
comfortable place for patients to wait while a prescription 
is being filled, and if the pharmacy is located so that 
patients have to pass it upon exiting the building, one may 
anticipate a certain percent of the building's scripts will be 
filled at the building's pharmacy. Maintenance drugs are 
often ordered through mail-order pharmacies under con- 
tract to insurance companies. 

If the pharmacy is part of a group practice, it is antici- 
pated that perhaps 40 percent of the group's prescrip- 
tions will be filled at its own pharmacy. If the pharmacy 
happens to be located in a medical complex, but it is in 
a separate building and the patient has to walk outdoors 
to reach it, perhaps less than 30 percent of the building- 
generated prescriptions will be filled there. Some 
patients will remain loyal to local pharmacies near their 
homes or use ones that will deliver. Pharmacies in super- 
markets and discount superstores offer the convenience 
of grocery shopping while the script is being filled, fur- 
ther siphoning business away from the traditional phar- 
macy setting. 



Pharmacy 399 




PHARMACY 



960 SF 
Figure 9-29. Space plan for a pharmacy, 960 square feet. (Design: Jain Malkin Inc.) 



After the volume of prescriptions is determined, dis- 
play space must be defined. If the pharmacy will sell 
prosthetic devices (crutches, braces, artificial limbs, 
colostomy supplies, etc.), a fitting room and a large stor- 
age room should be provided. Undoubtedly, a certain 
amount of display space will be required, even in a pro- 
fessional pharmacy, for toothpaste, special soaps, first- 
aid items, personal hygiene supplies, nonprescription 
drugs, candy and chewing gum, and perhaps a limited 
line of cosmetics. 

One pharmacist can usually fill 50 prescriptions in a 
day, including compounding, packaging, and dispensing. 
If he or she can prepackage certain frequently used med- 
ications, scripts per day can be boosted to 70 per phar- 
macist. That is, certain physicians who are major sources 
of scripts may routinely prescribe certain medications in 
standard dosages. If the pharmacist knows this, he or she 
can, during slack periods, prepackage these items and 
store them on a shelf. When a patient requests them, only 
a label need be typed, and the script is complete. 

Each pharmacist requires 4 to 5 feet of countertop 
work surface for compounding and another 2 to 3 feet of 
countertop for typing and labeling. Space is also required 
for a computer, printer, and fax machine. Each worksta- 
tion needs a phone. A full-size refrigerator and a built-in 
cabinet with a double sink should also be provided. 
Adjustable open shelving 8 to 10 inches deep is all that is 
required for storage of pharmaceuticals. Twelve lineal feet 
(6 feet high) of shelving is a minimum, with an additional 
4 lineal feet per pharmacist. 

The dispensing area often has a raised-platform floor 
(8 inches above the display and sales area floor), a 
required 5-foot-high security wall separating the dispens- 
ing and sales area, a required bathroom, and a bulk stor- 
age room. Sometimes a small private office is included. 
The bathroom is a code requirement based on the rea- 
soning that the pharmacist should never have to leave the 
store unattended to use a public restroom. A profession- 
al pharmacy will occupy anywhere from 800 to 1200 
square feet of space (Figure 9-29). 



400 Paramedical Suites 



CHAPTER 10 



Practice of Dentistry 



The modern dental office is truly a high-tech/high-touch 
environment. As a professional group, dentists have, for 
years, been well attuned to marketing and customer satis- 
faction. This may be due to the fact that, as the incidence 
of tooth decay and gum disease decreases, many dental 
procedures have become elective in nature unlike medical 
procedures, which are generally not elective. In dentistry, 
with the exception of oral surgery, endodontics (root 
canal), and sometimes periodontics (gum surgery), many 
treatments are done less for curing disease and restoring 
health than for quality of life. For this reason, cosmetic 
(esthetic) dentistry has been on the rise in recent years. 

Dentists were among the first to advertise; to use color- 
coordinated uniforms; open offices in shopping malls; and 
to attend seminars on office design, stress reduction, and 
the psychology of dealing with patients. 

Some dentists have what is called a values-driven prac- 
tice, in which the staff have been trained to redefine their 
roles.The practice philosophy of "drill, fill, and bill" is replaced 
with one of bringing wellness to patients and improving the 
quality of their lives. Staff are trained to listen to patients, inter- 
pret behavior, and respond positively to confrontation and 
problems. Employees learn pleasanttelephone manners and 
how to discuss financial arrangements without offending 
patients. Dental teams are aware of their self-image. They 
practice time management and stress reduction, and they set 
goals together. A values-centered staff makes it easier for 
patients to accept and want fine dentistry. 

Progressive dentists with finely tuned management 
skills are a source of many satisfying design projects. 
These dentists want both their personnel and their physi- 
cal environment to make people feel comfortable and con- 
fident about receiving care. To satisfy these dentists, the 
dental design specialist must be continually educated in 



changes in technology and in dental practice manage- 
ment. Fortunately, with the Internet, superb educational 
resources are available to anyone willing to spend the time 
visiting the Web sites of the professional dental associa- 
tions and dental practice management magazines, as well 
as various Web sites developed by dentists for the benefit 
of their colleagues offering advice on incorporating tech- 
nology into their practices. Dentists, as a group, have his- 
torically embraced new technology, rather than feared or 
resisted it. And the past two years have really kicked tech- 
nology into high gear for dental practices. 



HIGH-TOUCH PATIENT AMENITIES 

Many adults fear and dread a visit to the dentist as a result 
of painful and frightening childhood experiences. When 
they enter the treatment room, their blood pressure 
becomes elevated, muscles constrict, and stress hor- 
mones are released into their bloodstream in a classic 
"fight-or-f light" response. This prevents many from seeking 
anything other than emergency care for an abscess, root 
canal, or periodontal disease that may have progressed to 
an advanced state. These individuals do not seek elective 
procedures or cosmetic dentistry. However, if they have a 
positive treatment experience that is relatively painless 
and interventions are in place to relax them and to reduce 
stress, it is possible to change their negative childhood 
associations. The overall ambience of the office from the 
time they enter the waiting room is the first line of defense 
(Figures 10-1 and 10-2). First impressions do matter. 
Interesting ceiling design, indirect lighting, art glass, an open 
and welcoming reception desk, and color palette can do 
much to put people at ease (Color Plate 32, Figures 1 0-3 and 



401 



10-4, and Figures 10-5 and 13-10). In the dental treat- 
ment room amenities such as DVDs or videos are very 
effective as pleasant diversions. Offering options and 
choices allows patients to feel more in control in a threat- 
ening situation. 

There are no lengths to which dentists will not go to 
make patients feel comfortable and relaxed. Some of 
these amenities include an electric massage pad laid on 
the dental chair, heated aromatherapy pillows, a warm 
blanket, chairside CD player with headphones, virtual- 
reality glasses, ceiling-recessed monitor with video 
movies, hot towels and fruit juice at the end of treatment, 
a frozen-yogurt machine, the aroma of freshly baked 
bread for early-morning arrivals, and a great selection of 
magazines. Research shows clearly that having options 
and choices reduces stress and one of those choices 
should be "no bells and whistles." In the end, it is compe- 
tent and caring staff and building relationships with 
patients that really results in financial success. Dentists' 
Internet Web sites are rife with anecdotal reports of imag- 
inative things that have been implemented to comfort and 
entertain patients, but they usually end with the admoni- 
tion: They did not increase revenue or patient base 
although that's really not the fundamental reason for 
doing them. They, as well as numerous practice manage- 
ment gurus who run seminars, advise that well-trained 
staff who are courteous and trained in understanding dif- 
ferent personality types and how they react in stressful 
situations will prove to be a long-term asset. 
Nevertheless, it is worthwhile to distract and entertain 
patients in the treatment room as a considerable body of 
research demonstrates that such diversions are highly 
effective in reducing stress, especially in a clinical setting. 



INTERVIEW QUESTIONNAIRE— AN IMPORTANT 
DESIGN TOOL 



and equipment. Prior to filling out the questionnaire, a 
general discussion should occur relevant to the doctor's 
long-term goals — perhaps a 10-year plan. Is the goal to 
bring partners into the practice, to get this one going and 
then open other locations, or to retire in 10 years and sell 
the practice? This information will influence the project 
budget, space allocation, room for growth, and equipment 
selections. 

The information gathered from the questionnaire can 
be translated into an effective space-planning program. 
Occasionally dentists moving into new offices will bring 
outdated dental equipment with them, which might 
necessitate a less-than-optimal treatment room layout. 
Others buy sleek, state-of-the-art equipment that allows 
the designer to create an efficient treatment room. This 
chapter will acquaint the designer with the equipment 
and general requirements for the practices of general 
dentistry (including prosthodontics and cosmetic den- 
tistry), pediatric dentistry (pedodontics), orthodontics, 
periodontics, oral surgery, and endodontics. While guide- 
lines will be given, remember that the organization of 
dental offices is somewhat less standardized than that of 
medical facilities, owing to the number of options in size 
and design of the operatory or treatment room. The 
equipment, the location of casework, and the preferred 
style of delivery of instrumentation (rear, over the patient, 
or side) will determine the size and layout of the treat- 
ment room. As an aside, the preferred term for operatory 
is now "treatment room" unless surgery is performed 
there, as in oral surgery, although many dentists still use 
the term "operatory." 

Therefore, although there is an optimal design of a 
treatment room, other choices will also be presented. 
That which is common to all dental suites will be dis- 
cussed under General Dentistry. Modifications required 
for other dental specialties will be discussed thereafter. 



Dentistry allows for highly personalized practice methods, 
which must be set by the dentist before the space planner 
can begin. The interview questionnaire in the Appendix of 
this book is useful for documenting practice preferences 



PLAN THE SPACE BEFORE SIGNING A LEASE 

Dentists tend to do the same thing that physicians do — 
namely, to lease a space prior to engaging a space planner. 



402 Practice of Dentistry 




Figure 10-1. Waiting area is furnished like a residential living room with seating 
grouped around the fireplace; architectural detailing complements the design. 
(Rendering courtesy: Signature Environments, Inc, Seattle, WA.) 



Interview Questionnaire — An Important Design Tool 403 




Figure 10-2. Rustic detailing enhances the character of a dentist's wait- 
ing room/reception area. (Rendering courtesy; Signature Environments, 
Inc., Seattle, WA.) 



404 Practice of Dentistry 



While the dentist may know that he or she needs four 
treatment rooms to be functional, without a space plan, it 
will be impossible to know how that space will lay out and 
if it will yield four treatment rooms of optimal size. This is 
affected by the shape of the space, the location of struc- 
tural columns, as well as the overall dimensions of the 
area and perhaps the desire to have north light in the 
treatment rooms. A wiser course of action is to meet with 
a space planner prior to committing to the space. If the 
configuration of the space results in an awkward layout, 
undersized treatment rooms, and poor adjacencies with 
respect to critical functions such as sterilization and over- 
all flow through the office, it is better to recognize these 
conditions early rather than have to live with them for the 
next 1 years. Another space in the building may be avail- 
able that would result in a better layout. As dentists know 
well, efficiency makes a tremendous difference, whether 
it is a convenient reaching distance while seated at the 
dental chair, the number of staff it takes to run the office, 
or the resulting stress inefficiency places on the dentist 
and chairside assistants as they move through a busy 
schedule. 



Extraordinary Teamwork Required 

The design and construction of a dental office require a 
level of team collaboration and coordination that has no 
parallel in the design of a medical office. A matter of inch- 
es can make a critical difference in the efficiency of a 
treatment room. The interior designer or architect's role 
is analogous to that of a symphony conductor, carefully 
timing and integrating all the instruments or, in this case, 
the work of the dental equipment planner, audiovisual 
media consultant, electrical and mechanical subcontrac- 
tors, and dental equipment installers. A good general 
contractor experienced at building dental offices is 
essential. The complexity of this effort cannot be under- 
estimated — precision is everything. 




Figure 10-5. Waiting room features a built-in magazine rack and leaded glass windows 
reminiscent of Frank Lloyd Wright designs. (Space planning and interior design: Janet 
Pettersen, IIDA, Design Wave, Fallbrook, CA; Photographer: Jain Malkin.) 



Plan the Space Before Signing a Lease 405 



CODES AND REGULATORY 
AGENCY REVIEW 

A review of codes should start with the State Business 
and Professions Code if one exists. The State Dental 
Board and Public Health Department should also be 
consulted. Any or all of the above may have policies and 
procedures relevant to infection control, pharmaceutical 
control log, calibration of equipment, patients' rights, and 
so forth, some of which have no impact on the physical 
design of the office. If the dentist uses general anesthe- 
sia (oral surgery, pediatric, or restorative/esthetic den- 
tistry cases), this triggers many code issues as the 
patient is deemed "at risk for loss of life-preserving pro- 
tective reflexes." In some states, the use of general anes- 
thesia mandates licensing by the department of health 
services, Medicare certification, or accreditation by a 
recognized agency. These issues are explained in detail 
in Chapter 4 under Plastic Surgery, headings Office- 
based Surgery and Accreditation, Licensing, and 
Medicare Certification. See also Chapter 7, under 
Ambulatory Surgical Centers, heading Storage of 
Medical Gases, and Chapter 15, Researching Codes 
and Reference Materials. 



ADA is interpreted differently by building departments 
even within the same region with respect to treatment 
rooms and task areas such as sterilization. For example, 
since a person in a wheelchair may not be able to perform 
the tasks required of a dental assistant in the treatment 
room or sterilization area, the 36-inch clearance for a 
wheelchair on the assistant's side of the room may not be 
required, nor would the opening for room entry, in this 
case, be required to be 36 inches since the opening on 
the dentist's side would be 36 inches. Other jurisdictions 
require 36-inch clearance on all sides of the dental chair 
as well as wheelchair clearance under every sink in a 
treatment room. It has been reported to the author (but 
not verified) that OSHA has an interpretive newsletter 
that, in essence, states that task-oriented stand-up work- 
stations at the ADA limit of 34-inch height can injure the 
worker's back. As a result, in some jurisdictions steriliza- 
tion workstations are approved at 36-inch height. 

Dentists are accustomed to packing a lot into small 
spaces. Tiny darkrooms, labs, or break rooms with doors 
opening into the room barely scraping the edge of the 
cabinet are no longer possible under the Americans with 
Disabilities Act design restrictions. All rooms must be 
wheelchair accessible and have an 18-inch wall area on 
the pull side of the door. 



ADA (Americans with Disabilities Act) 

The ADA applies to medical and dental offices. Most 
architects and designers are very familiar with ADA regu- 
lations. Since there is no formal local enforcement of this 
national civil rights legislation, it is local building depart- 
ments that review it during the plan check. Building 
inspectors can be quite rigorous about compliance to the 
point of taking out a measuring tape and not approving a 
door setback that is supposed to be 18 inches on the pull 
side, if it falls short by even an inch. The same is true for 
toilet rooms, all of which must be ADA compliant unless it 
has access only from the doctor's private office and that 
person is an owner of the building. 

It seems, however, based on discussions with a num- 
ber of architects and planners of dental offices, that the 



Building Codes and Construction Methods 

Refer to Chapters 14 and 15 for relevant information on 
these topics. In most cases, these issues are the same for 
medical and dental offices. 



OSHA (Occupational Safety and Health 

Administration) EPA (Environmental Protection 

Agency) 

To avoid redundancy, the reader should refer to Chapter 
3, heading OSHA Issues for a discussion of standards 
affecting medical and dental offices. What follows is a dis- 
cussion of items specific to dental practices. It should be 



406 Practice of Dentistry 



noted that around the country a number of OSHA com- 
pliance consultants are available to dentists and physi- 
cians to survey their offices for proper techniques and 
also to train staff. OSHA usually sends inspectors only if 
a complaint is filed. 

EPA Disposal Requirements 

Film Processing. The EPA is concerned with the capture 
and certified disposal of film-processing solutions or, at 
least, the fixer. This is in effect in almost all states, 
although some allow silver recovery systems to process 
fixer with disposal into the city sewer system. Of course, 
the darkroom will become extinct as digital imaging 
becomes widespread. 

Amalgam and Mercury. In some states, old amalgam 
removed from patients and collected by traps in the office 
vacuum system must be disposed of through certified haz- 
ardous waste haulers. The amalgam also contains mercu- 
ry, which is regulated as parts per million (ppm) in the air. 
Chances are more sophisticated gathering of amalgam 
and residual mercury will be available in the near future. 

Lead from Film Packets. The storage of lead from intra- 
oral X-ray film packets after processing and certified dis- 
posal is fairly common, but this does not affect design as 
several years' collection of wrappers can be compressed 
into a 1 -cubic-foot box. 

Hazardous Waste and Sharps. There is a gap between 
what OSHA considers biohazardous (medical) waste 
within the working environment and what the EPA con- 
siders hazardous waste during disposal. OSHA man- 
dates that any material or waste that has contacted sali- 
va or blood be stored within the office in marked waste 
containers declaring it as biohazardous. This is ostensibly 
to alert employees not to reach into these waste contain- 
ers unprotected or to handle the waste during disposal 
without proper barriers in place. The EPA, however, does 
not consider the same waste, in general, as hazardous 
after it leaves the dental office. The concentration of blood 
and saliva is seldom significant enough to cause a health 



hazard. The problem lies in the misinterpretation of how 
to dispose of the waste. If it is red bagged, then the EPA 
and the waste haulers and landfill personnel must treat it 
as biohazardous medical waste. However, if it is disposed 
of properly, no special precautions are necessary during 
disposal. 

Sharps can be stored in a new type of sharps contain- 
er, called an Isolyser, which is filled with a high level of 
liquid disinfectant. Once the container is full, a catalyst 
powder is added and the solution becomes an impene- 
trable mass of polymer that seals all of the sharps from 
the environment. A label is applied over the original 
BioHazard emblem declaring the waste as treated and, 
as solid waste, it can be disposed of like any other trash. 
Refer to the Casework and Modular Cabinetry sections in 
this chapter for ideas to accommodate sharps containers 
and waste collection neatly and out of view in the treat- 
ment room. The designer needs to check local codes to 
see if the office needs a separate storage area (usually a 
small room or closet near the staff or service entrance) for 
biohazardous waste until the certified hauler removes it. 

OSHA 

It should be noted that OSHA has both state and feder- 
al agencies. National OSHA standards may be inter- 
preted differently by state OSHA agencies. Both must be 
consulted. 

Hazardous Materials Standard. All materials an 
employee comes into contact with must be examined for 
known health or safety hazards and labeled if found to be 
dangerous. This involves mandatory record keeping of 
an inventory of hazardous products and a readily avail- 
able book of MSDS (Materials Safety Data Sheets) for 
reference in case of spills or contact with hazardous 
materials. Offices must have an eyewash diverter device 
or a dedicated eyewash in any area in which hazardous 
materials are used. It must be placed where an employ- 
ee can reach it within 10 seconds of occurrence, which 
generally means placing it in the sterilization area, pos- 
sibly the dental lab, and the darkroom. A faucet diverter 
device (see Figure 3-51) is often used, but it has the 



Codes and Regulatory Agency Review 407 



potential to cause additional injury if the injured worker 
accidentally turns on the hot water instead of the cold 
water. A permanent eyewash station has only a cold- 
water line. The types of hazardous materials that may be 
found in a dental office are phosphoric acid, sodium 
hypochloride, phenols, hydrofluoric acid, film developer 
and fixer. In the dental lab, fumes from methyl methacry- 
lates and ethyl methacrylates need to be exhausted to 
the outdoors, not the plenum. This requires a good ven- 
tilation fan. 



age particularly at risk of miscarriage, premature births, 
and infants born with low birth weight. Some states have 
mandated that an electronic monitoring system be 
installed to alert staff when the acceptable level ppm 
(parts per million) of N 2 has been exceeded. Proper 
placement of this monitoring system is a design factor, 
which will also impact HVAC design. A high number of air 
changes per hour is essential in all treatment rooms. Air 
supply and return should be carefully studied to ensure 
adequate circulation. 



Bloodborne Pathogens Standard. This standard man- 
dates that employees be educated as to the methods of 
transmission of disease, proper use of personal protec- 
tive equipment, proper handling of waste and sharps, and 
the results of accidental needle sticks. Universal precau- 
tions should be taken with all patients. An often-over- 
looked design factor is the addition of a washer and dryer 
within the facility to launder barrier gowns. This also 
involves a storage area for clean gowns, which have 
either been laundered in the facility or sent out to a com- 
mercial laundry and subsequently delivered back to the 
dental office. A hamper is needed to collect soiled gowns 
until they can be laundered. Putting the washer and dryer 
or soiled-clothing hamper in the staff lounge is prohibited 
by OSHA. There must be a definite separation of food, 
cosmetics, and eye care products from items used in the 
clinical practice; likewise, one cannot take contaminated 
items into an area where food is prepared or consumed. 
A good location for the laundry area is near sterilization 
as the washer and dryer can be monitored during use. 
The hamper can be placed in the staff restroom if staff 
use this for changing clothing or it can be an isolated 
hamper next to the washer/dryer. If laundry is sent out to 
process, the hamper can be placed in the hazardous 
waste holding room (Figure 10-6). 

Nitrous Oxide Scavenging and Monitoring. OSHA 
mandates that effective scavenging systems be used dur- 
ing nitrous oxide sedation to prevent overcontamination 
of the air for dental personnel. Nitrous oxide leaks from 
the face mask, putting female employees of childbearing 



Water Quality 

This issue took center stage a couple of years ago as a 
result of investigative reports presented on several 
national TV news magazines. Water from a dental hand- 
piece or syringe was declared to be considerably more 
contaminated than water samples taken from public rest- 
room toilets when analyzed by an independent testing 
laboratory. As a result, many states have enacted legisla- 
tion mandating that water used during treatment have no 
more than 200 CFUs (colony forming units) per milliliter of 
contamination. Dental equipment is now designed to 
incorporate containers that can be filled with distilled 
water and mounted on the assistant's cart or on the den- 
tal console (Figures 10-7 and 10-8a). 

There are several methods for achieving good water 
quality in the dental office. 

1 . Design equipment to no longer use public water and 
instead use distilled water, reverse-osmosis water, or 
a new replacement solution. Even daily and weekly 
regimens for sterilizing or disinfecting the entire self- 
contained water system, using distilled water, do not 
guarantee that overcontamination will not occur with 
regular maintenance. This led to the development of 
an FDA-approved solution that can be added to regu- 
lar drinking water to constantly kill microorganisms 
and prevent biofilm buildup in the water system with- 
out harming the patient or affecting the efficacy of 
dental materials. Several of these now exist. 



408 Practice of Dentistry 



90-0' 




GENERAL DENTISTRY - GROUP PRACTICE 

4500 SF 

Figure 10-6. Space plan for general dentistry group practice, 4500 square feet. (Design: Jain Malkin Inc.) 



Codes and Regulatory Agency Review 409 




Figure 10-7. Chairside assistant's mobile cart. Note container for dis- 
tilled water {Photo courtesy: A-dec, Newberg, OR.) 



2. Some manufacturers have effected a solution by run- 
ning the public water supply to the dental units 
through a device that meters in a product that kills 
microorganisms and prevents biofilm buildup. 

3. Use public water but install an ultraviolet sterilization 
chamber and/or ozone treatment device on the water 
supply at each chair. 

4. Use the public water system but install disposable fil- 
ters on each water line to a dental unit just prior to the 
water being discharged into a patient's mouth. 

All these methods must be approved by the FDA and the 
designer must establish which method the practitioner 



wishes to employ as it affects water supply design criteria. 
It should be noted that almost all states and municipal- 
ities now require a separate RP (reduced pressure) back- 
flow preventer on any public water line connected to a 
dental unit regardless of what devices the dentist has put 
in place to treat the water. This device is too large to put 
into the standard dental equipment junction box, so it must 
be mounted remotely. This can be either cost prohibitive or 
space prohibitive, in which case, the first solution listed 
above would be the most practical alternative as it does 
not require city water plumbed to the dental unit. 



Exposure to Radiation 

The safe use of X-ray machines is generally regulated by 
the State Board of Health and assigned to a radiological 
health subdepartment. OSHA only inspects facilities to 
make sure they are following these regulations as they 
pertain to the protection of employees. OSHA, itself, has 
no specific radiology standards. Regulations affecting the 
design of dental suites follow. 

1 . Most states require that a health physicist review floor 
plans and potential locations of equipment to deter- 
mine proper radiation barrier materials and acceptable 
locations for operating controls. The physicist will need 
to know the specifications of the X-ray equipment with 
respect to radiation emitted and the anticipated usage 
or volume of films for each machine. The physicist will 
consider construction of walls, adjacent occupancies, 
and construction of floors and ceilings that separate 
this space from others above and below. Required bar- 
riers for dental X-rays are minimal compared with med- 
ical radiology equipment. The physicist's report must be 
submitted to the building department along with the 
construction documents. 

2. The federal minimum barrier requirement for dental- 
type X-ray machines is a standard wall constructed 
with wood or metal studs and covered on both sides 
by one layer of %-inch-thick gypsum board. An opera- 



41 Practice of Dentistry 



tor does not need to be behind an approved barrier as 
long as he or she is 72 inches or more from the 
source of the radiation and not in the primary beam 
trajectory. No one other than the patient can be in the 
primary beam trajectory, which means approved bar- 
riers must exist to prevent exposing staff or patients in 
adjacent areas during X-ray. 

Typically, the only lead barrier requirement is immedi- 
ately behind a cephalometric X-ray head holder and 
only if the space behind it is routinely occupied, 
although some states have more rigorous standards. 
This may include lead lining in modular dental furniture 
systems and/or in stud and drywall partitions. When a 
secondary entrance to the room exists, a photoelectric 
eye deactivation of the X-ray beam may be required if 
someone tries to enter during an exposure. Through- 
the-wall X-ray cabinets may be required to have 
switches on cabinet doors so that the X-ray will work 
only when one set of doors is fully closed. 

A cephalometric X-ray device is generally found only 
in orthodontic and oral surgery practices, but may 
occasionally be found in general dentistry practices 
as well. State guidelines often require that the X-ray 
machine operator be able to see the patient during 
the exposure of a panoramic X-ray because the 
patient is essentially trapped inside a moving machine 
and can be injured if he or she tries to exit unexpect- 
edly during exposure. Some states have misinterpret- 
ed this requirement and mandated that the operator 
be able to see the patient during any X-ray exposure. 
It is important to check requirements with the state 
agency and then provide a location for the operator 
that allows viewing of the patient from behind an 
approved barrier or from a distance 6 feet away from 
the radiation source and never in the primary beam 
trajectory. The use of leaded-glass operator viewing 
windows is probably the most common method for 
compliance. Refer to Chapter 5 for examples of pro- 
tective barriers and resources. Nuclear Associates in 
Carle Place, New York, is a major supplier of lead- 
impregnated acrylic barriers. 



3. Most states have laws that cover the design of the 
darkroom as well as the developing process and 
exposure. Poor technique forces a practitioner to take 
needless additional exposures. An absolutely light- 
proof room, but with good ventilation, is required. 
Refer to Chapter 3 for details on darkroom design 
and to Figure 1 0-78 for a diagram. The safelight must 
be filtered with a Kodak GBX filter or equal and must 
be located a minimum of 36 inches from the work 
surface and the input to the film processor. The EPA 
and local health regulations should also be checked 
with regard to disposal, treatment, or capture of 
chemicals. 



NEW TECHNOLOGY TRANSFORMS THE 
DENTAL OFFICE 

New technology is changing the fundamental way den- 
tists practice, making it possible to achieve a level of inte- 
gration and efficiency in practice management that is 
almost effortless once the proper software and hardware 
have been employed and networked. Think of the typical 
series of documentation and communication steps 
required for charting treatment, scheduling visits, dis- 
cussing costs, documenting insurance codes, preparing 
lab slips, recording payments, filing insurance claims, and 
sending out statements. The same information is written 
or typed over and over with much repetition and little 
value gained. Think about a typical day's schedule and 
the total number of patients for which these multiple 
entries must be made and also consider the possibilities 
for error. One procedure for an individual patient can 
require as many as 15 entries, which results in high over- 
head and job security for office staff. 



The Paperless Office 

In the paperless office, there is total connectivity among all 
aspects of practice management and clinical care. 
Computers located at all workstations, including treatment 



New Technology Transforms the Dental Office 41 1 




Figure 10-8a. Treatment room features practice management monitor at 12 o'clock wall and doctor/patient flat-screen monitor on radius arm. The Preference Collection {Photo courtesy: 
A-dec, Newberg, OR.) 



41 2 Practice of Dentistry 




I 


1 


1 


1 


/\l§0. 




^Pc 









Figure 10-8b. Treatment room with dual cart rear delivery for doctor and chairside assistant. The Preference Collection (Photo courtesy: A-dec, Newberg, OR.) 



New Technology Transforms the Dental Office 413 




Figure 10-9. Treatment room depicting side delivery of instrumentation and doctor/patient flat-screen monitor on 
articulating arm secured to side cabinet. (Photographer: Jain Malkin.) 



rooms, enable a seamless transfer of information that 
starts with scheduling the patient and ends with electron- 
ically processing insurance claims. Recall appointments 
can be scheduled from the treatment room without hav- 
ing to rely on one pivotal person at the front desk as the 
chief appointment maker. In small offices, the person 
seated at the front desk often runs the show, sending out 
statements as well. When he or she is absent, the prac- 
tice may come to a grinding halt. Cross-training enables 
support staff to do several jobs, creating a situation 
sometimes known as "frontdesklessness." As chairside 
assistants become more comfortable with computers, 
they can post procedures, schedule, and even accept 



payment right in the treatment room. This frees the front 
desk assistant to focus on sending marketing letters to 
patients and collecting accounts receivable and insur- 
ance, in addition to general overview of scheduling, post- 
ing payments, and handling in-office collections. There is 
another benefit to blurring the roles between front and 
back office staff who are sometimes critical of what they 
view as the others' shortcomings and lack of understand- 
ing of the importance of what they do. By having cross- 
trained staff who literally step into each other's shoes, it 
builds teamwork and uses everyone's time more effec- 
tively. Hygienists, for example, can schedule their own 
recalls as the patient is leaving the treatment room if they 
have a computer at their disposal. 



Multiple Applications for 
Treatment Room Computers 

In a paperless office, any notes or letters from referring 
dentists are scanned into the patient's electronic clinical 
record, which is easier to access and takes less space to 
store, can be transmitted to other locations, and is less 
likely to be lost, assuming proper back-up procedures are 
followed. Once the computer is in the treatment room, 
there is an array of peripheral items that can be added 
such as cosmetic imaging, digital X-ray, digital intraoral 
camera, and software for presenting complete treatment 
plans with estimates of cost, as well as patient education 
and entertainment programs (Figures 10-8b and 10-9). 
High-tech dental offices have totally integrated, multiple- 
application, seamless computer systems that result in 
improved practice management and enhanced diagnostic 
capabilities, giving patients a better understanding of nec- 
essary restorative treatment and what constitutes optimal 
dental health. Having a computer in the operatory pro- 
vides greater ability to access, process, and store large 
quantities of data with instantaneous retrieval. The real 
benefit is that patients are being better served: Intraoral 
video cameras, digital radiography, and chairside micro- 
scope magnification improve the ability to find and treat 
problems earlier. 



41 4 Practice of Dentistry 



The Technology Wave 

Intraoral Video Camera 

The intraoral video camera enables intraoral or extraoral 
visualization at magnification from 5x to 35x, depending 
on the mode. It is the greatest visual tool for dentists since 
the mirror. The system consists of a handpiece (which is 
actually a tiny lens) that looks like a pen, a docking sta- 
tion with fiber-optic system, and a video monitor (Figure 
10-10), although the images can be displayed on any 
monitors in the room. An optional printer produces color 
hard-copy images for patient and insurance use. Figure 
10-11 shows standalone and network configurations. A 
built-in freeze frame makes it easy to create a "show and 
tell" presentation for the patient, and, with appropriate 
software, images can be captured and downloaded to the 
patient chart or placed in a digital "photo album" for view 
at a glance of multiple images with dates, name, and 
patient identification. This software makes it easy to 
assemble case presentations by using the computer to 
search for images by type and then further refine the 
search by gender, age, tooth number, upper or lower, and 
so on. 

The intraoral camera is a significant diagnostic tool 
that enhances the visibility of areas of the mouth that 
are difficult to see and it also makes it much easier to 
educate patients about restorative treatment. The dock- 
ing station can be eliminated if the intraoral camera is 
integrated on the instrument console as it is in Figure 
10-12. This system makes it ergonomically easy for the 
dentist to manipulate images or access data on the com- 
puter due to the convenient tray for a cordless mouse or 
an integrated touch pad. Freeze-frame images can be 
saved to the patient chart by tapping a foot pedal. Air 
and water are also controlled by foot pedal. While many 
dental equipment manufacturers have adapted their 
patient chairs and dental consoles to accommodate dig- 
ital technology, the unit in Figure 10-12 is completely 
integrated without having to add separate items. Note 
also that the patient chair is cantilevered, creating a less 
bulky appearance. 




Figure 10-10. Intraoral camera and monitor. VistaCam OmniTM. (Photo courtesy:Air Techniques 
Inc., Hicksville, NY.) 



Extraoral Cameras 

Extraoral cameras are used to photograph the full face or 
smile. This can be used by imaging programs to show how 
the face will change after dental treatment. They are typi- 
cally used in orthodontic practices and also in cosmetic or 
esthetic dentistry. If a digital camera is used, the image can 
be directly captured by a software program that morphs 
the face to show how it will change with the proposed den- 
tal treatment. Newer dental offices often have an imaging 
room (Figure 1 0-6) where photos are taken and in which an 
assistant trained to manipulate the software can prepare 
cosmetic dentistry case presentations. The imaging area 
needs a countertop work surface to accommodate the 
monitor and keyboard and to provide a place for the assis- 
tant to work. This room may also contain a panoramic or 
combination panoramic/cephalometric X-ray. 



New Technology Transforms the Dental Office 415 



Stand-Alone 
Configuration 



Network Configuration 




Foot switch 



*■ AcuCam* Linx 

M li I (ifi lexer 



► CentraJly- 
Located Primer 




Stand-Alone 
Configuration 



Network Configuration 



CO* 






Figure 10-11. Diagram of intraoral camera configurations. (Illustration courtesy: Dentsply International, Gendex Dental X-Ray Division, Des Plaines, IL.) 



41 6 Practice of Dentistry 



Digital Radiography 

The advantages of digital dental radiography are numer- 
ous. It eliminates the cost of film, chemistry, and proces- 
sors. It eliminates the darkroom and the need to clean the 
processor roller rack as well as the need to dispose of the 
lead film packs and processor chemicals. In addition, it 
exposes patients to considerably less radiation, and 
issues of under-or overexposed film are resolved by 
being able to manipulate a digital image. Digital radiogra- 
phy is discussed in detail later in this chapter. 

Operating Microscope 

Ceiling- or wall-mounted microscopes in the treatment 
room are used by anyone who desires to see better: 
endodontists, prosthodontists, periodontists, general den- 
tists, and, most recently, dental hygienists (Figures 10-13 
and 10-1 4). The operating microscope enables dentists to 
work at high-level magnification (2X-21X) coupled with 
coaxial illumination. Telescopic loupes (eyeglasses only) 
provide 2- to 4-power magnification. The microscope may 
have accessories added such as video cameras, digital 
cameras, 35-mm film cameras, and/or a dental assis- 
tant's binoculars. Operating microscopes are being built 
into many offices today due to the significant ergonomic 
advantage of being able to sit up straight, looking forward 
at the microscope, rather than bending over the patient. 
This reduces head and neck injuries (Figure 10-14). 

Networked Computer Systems 

Networked multiple treatment room computer systems 
integrating clinical software, digital X-ray, and dental prac- 
tice management software create a paperless office and 
a seamless transfer of information. 




Figure 10-12. Digital technology has been integrated into the design of the Prostyle Compact dental unit, elimi- 
nating the need to connect a number of separate items. The intraoral camera is one of the handpieces. Air and 
water are controlled by tapping a foot pedal. (Photo courtesy: PLANMECA, INC., USA, Addison, IL.) 



Dual Monitors 

Each treatment room will have monitors for the patient 
and clinical staff. 

Air Abrasion 

Air abrasion is an alternative to conventional high-speed 
handpiece (drill) dentistry; however, it is appropriate only 



New Technology Transforms the Dental Office 417 




Figure 10-13. This treatment room has a ceiling-mounted operating microscope and 
TV monitor as well as centrally piped medical gases (note faceplates at toe of chair, 
left side). Glass shelves in front of patient display art objects. {Photo courtesy: 
Cherilyn Sheets, D.D.S.; Photographer: Jain Malkin.) 



for certain types of treatments. A small stream of particles 
(powder), under extremely high pressure, literally dis- 
solves cavities. It generally does not require anesthesia 
and is therefore quite appealing for small children. When 
the decay is removed, a small tooth-colored filling is 
inserted. Air abrasion can also be used as a diagnostic 
tool to probe hidden decay in lieu of "watching and wait- 
ing" for a potential problem to get worse. It is minimally 
invasive and eliminates the vibration and microfracturing 
associated with rotary handpieces. It is often used with a 
rapid curing light that cures composite materials or 
bleaches quickly, compared with conventional methods. A 
large machine, on casters, the air abrasion equipment 
can be moved from room to room (Figure 10-1 5a), and 
some modular casework systems have created a 
recessed niche for it (Figure 10-43). 

Cosmetic Imaging 

With the advent of digital cameras, photo-quality ink-jet 
printers, and inexpensive image capture software, cos- 
metic imaging is taking center stage to help dentists 
demonstrate esthetic treatment results to patients. 
Cosmetic cases can involve extensive work and high fees. 
Dramatically changing someone's smile is professionally, 
as well as financially, rewarding compared with routine 
dentistry and discounted fees paid by dental plans. 

Lasers 

Lasers have been developed for both hard and soft tis- 
sue. They can be used to treat periodontal disease in a 
process called root planing. After tartar is removed using 
an ultrasonic scaler, the erbium laser is used to reduce 
bacteria associated with periodontal disease. A diode 
laser enables cosmetic dentists to sculpt the gum line. 
Not as common is the laser developed for hard tissue. 
These may be used for removal of tooth decay and cavi- 
ty preparation as well as resin restorations. In the future, 
it is expected that they will be used in oral surgery and for 
cleaning out root canals in endodontic practices. 
Presently, research shows no differences in postoperative 
results compared with cavity preparation in the conven- 
tional air turbine/bur technique, except that laser treat- 



41 8 Practice of Dentistry 



merit does not require local anesthesia. Lasers are some- 
what controversial in dental practice: Some practitioners 
currently see no need for lasers and, in fact, have quite 
negative opinions about their usefulness, while others 
find them very useful for specific procedures. Many den- 
tists prefer electrosurgery to lasers. For dentists who use 
them, there are no special space or design accommoda- 
tions that need to be made. They are portable and can be 
moved from room to room. As the beam is narrowly 
focused in the mouth, it doesn't pose any environmental 
safety hazards; lasers are often used in treatment rooms 
without doors. The patient and clinical staff must wear 
goggles to protect their eyes and a sign must be posted 
when lasers are in use. Most states require that lasers be 
licensed like X-ray machines. 

Chairside Patient Education/Entertainment 

Patient education includes viewing images taken by the 
intraoral video camera, looking at digital X-rays, and 
watching DVD presentations on specific dental proce- 
dures or problems. CAESY®, an acronym for Clinically 
Advanced Education System (available from Dentistry 
Online, Inc., Vancouver, Washington), offers 2- to 3 1 / 2 - 
minute video presentations enhanced by clinical photos 
and computer animation and narration explaining peri- 
odontal disease, root canal, and dozens of other proce- 
dures. While the assistant is readying the treatment 
room or while waiting for the local anesthetic to take 
effect, the patient can be educated so that the dentist's 
time can be optimized by not having to explain the pro- 
cedure. CAESY also supports the hygienist by eliminat- 
ing repetitive treatment explanations, saving time, and it 
can be used by the treatment planning coordinator to 
prepare effective case presentations. The Smile 
Channel®, also available from Dentistry Online, in DVD 
format, can be used in the waiting room or the treat- 
ment room to stimulate a desire for cosmetic dentistry. 
In discussing topics like veneers, bonding, and teeth 
whitening, it demonstrates how the smile can be 
changed. It also has humorous programming for chil- 
dren using animals who "visit" the dentist to learn how 
to take care of their teeth. 




Figure 10-14. Endodontist using ceiling-mounted operating microscope, which enables the doctor to 
sit erect during the procedure rather than bent over the patient's head. {Photographer: Jain Malkin.) 



New Technology Transforms the Dental Office 419 




.! 

Figure 10-1 5a. Air abrasion 
system, AirDent II™ (11 inches 
wide x 24 inches deep x 28 
inches high), can be moved 
from room to room. (Photo 
courtesy: Air Techniques Inc., 
Hicksville, NY.) 




Figure 10-1 5b. The CEREC 3 (Chairside Economical Restorations of 
Esthetic Ceramics) produces, at chairside, fillings, veneers, onlays, and 
crowns. (Photo courtesy. Sirona USA, LLC, Charlotte, NC) 



For entertainment, virtual-reality glasses and pro- 
gramming may be more appropriate for children than 
adults as the nature of the device is somewhat of a bar- 
rier in establishing rapport between the patient and den- 
tist. Making eye contact during treatment is important. 
Once the initial dialogue with the patient has ended and 
treatment begins, entertainment can be very useful in 
distracting patients to reduce anxiety. This includes 
videos of calming nature scenes (desert, tropical rainfor- 
est, beach and surf) as well as satellite TV and music, 
all of which can be controlled by the patient with a 
remote-control device. 

Computer-Aided Restoration with Electronic 
Impressions 

The CEREC 3 by Sirona uses CAD/CAM (computer- 
aided design/computer-aided manufacturing) to produce, 
at the chairside, fillings, veneers, onlays, and crowns 
(Figure 10-1 5b). Instead of several return appointments 
and temporary inlays or crowns, it can all be done in one 
appointment. The CEREC takes an electronic "impres- 
sion" (no gooey impression material in the mouth), and 
the computer creates the restoration. Using an adhesive 
bonding technique, the dentist inserts the filling into the 
tooth or cements the crown. This eliminates having to 
send the impressions to a lab and waiting a couple of 
weeks for return of the crown. The conventional material 
for crowns is porcelain fused to metal, whereas the 
CEREC (chairside economical restorations of esthetic 
ceramics) uses ceramic material. There is some debate 
about whether ceramic crowns have the subtlety of col- 
oration and artistry produced by the finest porcelain lab- 
oratories. Today, dentists have the capability of sending 
the laboratory a digital color photo of a patient's mouth 
with the standard tooth-matching color guide included in 
the photo as a visual reference to correct for differences 
in color reproduction on the monitor and/or printer 
receiving the image at the lab. Currently, the CEREC is 
not widely used in the United States because it takes 
considerable training and good technique to use it prop- 
erly. In addition to chairside, it can also be used in an in- 
house dental lab. 



420 Practice of Dentistry 



Teeth Whitening 

Increased awareness of beautiful smiles and white teeth 
has created demand for whitening or bleaching. This was 
formerly accomplished (and still is) at home by use of a 
bleaching gel that is injected into clear plastic molds, cus- 
tom-made to fit the individual's teeth. Additionally, dentists 
can bleach teeth in their office by numerous methods, 
some of which have space implications. The large 
portable piece of equipment shown in Figure 10-16 
requires that the patient sit still in a dental chair for approx- 
imately an hour and a half with mouth held open by a 
device to enable a bright light to reach the teeth, where- 
upon it interacts with a bleaching solution. During the pro- 
cedure, the patient is distracted by watching a video. The 
unit may be kept in one of the hygiene treatment rooms. 

Water Systems 

Few dentists today use piped-in city water chairside in 
their treatment rooms due to awareness that microorgan- 
isms breed easily in standing water, which inadvertently 
exposes patients (especially those on Monday morning 
after water has been standing in the pipes all weekend) to 
health hazards. Manufacturers of dental equipment now 
routinely provide a container for distilled water mounted 
near the assistant's and/or dentist's handpieces (Figures 
10-7 and 10-8a). Minerals in city water can also adverse- 
ly affect the performance and longevity of handpieces, 
scalers, and syringes. 

Sterilization Procedures 

Sterilization techniques for instruments coming into con- 
tact with mucosal tissue during treatment must be 
processed, sterilized, and stored according to a higher 
standard of asepsis than has been common in the past. 
The CDC (Centers for Disease Control) suggests that all 
dental instruments be wrapped or bagged prior to sterili- 
zation and remain sealed until used. The Dental Board in 
each state or the Board of Public Health regulate asepsis. 
There are a number of states where it is not mandated by 
law that instruments be sterilized or packaged, but that 
number is diminishing as state regulators react to CDC 
guidelines by enacting legislation. The ADA (American 



Dental Association) has endorsed CDC regulations and 
made them the "standard of care," which has led many 
states to amend their practice acts accordingly. 

Consumers would be surprised to learn how lax regu- 
lations have been with respect to sterilization of instru- 
ments and handpieces. There is no agency inspecting 
dental offices in this regard. Expect more regulation in the 
future, especially if dentists begin to seek accreditation by 




Figure 10-16. BriteSmile teeth whitening system. {Photographer: Jain 
Malkin.) 



New Technology Transforms the Dental Office 421 



national agencies as many medical facilities must do in 
order for them to be eligible for Medicare and other third- 
party reimbursement. 

Modular Cabinetry 

Modular casework, as a generic item, is not new in den- 
tal treatment rooms, but the new generation of modular 
casework offers infinite possibilities for accommodating 
the numerous pieces of equipment that are now part of a 
high-tech treatment room, allowing for placement accord- 
ing to the practitioner's preference. Comparing the last 
generation of modular casework with the new generation 
(Figures 10-17, 10-18, and 10-19) tells the story. Also 
built into these units are dispensers for drinking cups, 
several sizes of gloves, and a tissue box, as well as the 
sharps container. The goal is to have everything out of 
sight when the patient enters the room and to open 
retractable and other doors and drawers after the patient 
is reclined in the chair. Note, in Figure 10-17, the pull-out 
shelf with keyboard and mouse and the ink-jet printer at 
the 12 o'clock wall. 

Vacuum 

There is a trend toward waterless (dry) vacuum systems 
because they save electricity, water, and sewage treat- 
ment costs; however, the greatest number of offices still 
use "wet seal" systems. Storage of old amalgam (silver 
fillings removed from patients) collected by traps in the 
office vacuum system must now, in many states, be dis- 
posed of through certified hazardous waste haulers. More 
sophisticated gathering of amalgam and residual mercu- 
ry will be available in the near future. These systems exist 
throughout Europe, but thus far lobbying in the United 
States has stopped most state legislatures from enact- 
ment of similar legislation. Choice of vacuum system 
affects space requirements for the unit as well as piping 
requirements; consult the doctor's dental supplier for 
accurate information. 

Safety Regulations 

These have been discussed in detail earlier in this chap- 
ter and include standards issued by OSHA and the EPA 



regarding disposal of hazardous waste and sharps, the 
Bloodborne Pathogens Standard, the Hazardous 
Materials Standard, and tighter regulations for asepsis to 
prevent cross-contamination. 



INFECTION CONTROL 

People in a dental setting, whether staff or patients, are 
exposed to a wide variety of infectious microorganisms in 
the blood and saliva of patients. Proper infection control 
procedures used in the treatment room, sterilization, and 
dental laboratory prevent cross-contamination. 

While much attention has been focused on AIDS, the 
dental team is much more at risk for hepatitis B and C. In 
1 982, the Council on Dental Therapeutics adopted a reso- 
lution recommending that all dental personnel be vacci- 
nated against this virus. And, in 1988, OSHA began 
enforcing mandatory compliance with CDC/ADA (Centers 
for Disease Control/American Dental Association) recom- 
mendations developed to protect dental staff and patients 
from the risk of contracting HIV or hepatitis B virus from 
one another. As it is difficult to determine whether a patient 
is a carrier of one of these dangerous viruses, each patient 
must be considered potentially infectious and the same 
universal precautions should be implemented. The dental 
team is required to wear protective eyewear, masks, 
gloves, and uniforms or gowns to create a protective barri- 
er between themselves and contact with blood, saliva, 
debris spatter, or aerosols. Head covers are recommend- 
ed during invasive procedures that are likely to result in 
splashing blood or other body fluids. Laundry service or in- 
office washers/dryers are now the only options available to 
the dental practice for cleaning of barrier garments since 
OSHA forbids employees from taking or wearing home 
contaminated garments to launder them. 

All surfaces within the treatment room must be able to 
be thoroughly cleaned and disinfected. The design of 
cabinetry should be simple and easy to clean, with few 
crevices. Wallcoverings, if used, should be smooth, and, 
although floors may be carpeted, a hard-surface floor will 
be easier to clean. 



422 Practice of Dentistry 




Figure 10-17. Triangle Furniture Systems, Inc., modular casework system for treatment room offers flexibility and storage for numerous individual pieces of equipment. (Photo courtesy: Patterson 
Dental Supply, Inc., St. Paul, MN.) 



Infection Control 423 




Figure 10-18. Modular treatment room casework, The Preference Collection™ features 12 o'clock wall with chairside assistant's monitor and keyboard; radius arm on dental chair 
enables flat-screen monitor to be positioned on patient's left when taking the X-ray image and on patient's right when explaining it to the patient. Note dental light is attached to 
casework. (Photo courtesy: A-dec, Newberg, OR.) 



424 Practice of Dentistry 



Dentists must cover any surfaces that may be contam- 
inated by blood or saliva, such as the handle of the den- 
tal light or the X-ray head, with clear plastic film. This 
wrapping should be changed between every patient. 
Surfaces that cannot be covered or removed for cleaning 
and sterilization must be scrubbed and disinfected 
between each patient. 



Select Finishes Carefully 

Interior designers specializing in healthcare design are 
familiar with many attractive interior finish materials that 
have the illusion of texture but, in reality, can easily be 
cleaned. There are exquisite fabrics that have all the 
maintenance and durability properties of vinyl upholstery, 
yet are actually woven textiles that have the appearance 
of natural linen or other fine fabrics. Some of these can 
even be cleaned with bleach. 

Upholstery fabrics, window treatments, wallcoverings, 
and flooring must be selected with asepsis in mind. 
Flooring in treatment rooms or operatories may be 
smooth sheet vinyl (the solid vinyl simulated woodgrain 
products are an attractive option). Many dentists prefer 
carpet for its acoustic properties and, contrary to popular 
wisdom, OSHA does not forbid carpet in treatment rooms 
as long as it is properly maintained. If carpet is used, it 
should be the type that has a laminated vinyl backing to 
prevent moisture from leaching up through the floor or, in 
the opposite direction, from the top through the backing 
into the slab or subfloor. Collins and Aikman and 
Mannington are two manufacturers that offer this option. 
Carpet should be directly glued to the slab. This provides 
a very firm surface on which to roll chairs. 

A highly washable alternative to standard paint is a 
sprayed finish like Zolatone™, which has a speckled multi- 
color appearance that is quite attractive, and less expen- 
sive, than vinyl wallcovering. Consider polyvinyl chloride 
(PVC) vertical louver blinds as an easy-to-clean window 
treatment. A number of other interesting and practical win- 
dow treatments have emerged in recent years using PVC 
mesh offered in different densities and a range of neutral 




Figure 10-19. Modular casework configuration, The Preference Collection™, which may be used on rear wall of a pri- 
vate treatment room. Both doctor's and assistants instruments are delivered from the rear. {Photo courtesy: A-dec, 
Newberg, OR.) 



Infection Control 425 




Figure 10-20. C8 Treatment Center with flat-screen monitor integrates patient communications (digital X-rays or 
intraoral camera images) with cabling concealed within the light post. {Photo courtesy: Sirona USA, LLC, 
Charlotte, NC.) 



colors in the form of a roller shade or a pleated Roman 
shade. These fabrics are designed to control sun without 
blocking the view as well as to cut heat gain on southern 
and western exposures. Two manufacturers of these sun 
shade products are Mecho Shade (Phoenix, Arizona) and 
Solar Shade (Santa Ana, California). Chapter 12 provides 
a detailed discussion of appropriate finish materials for 
medical and dental offices and also discusses furniture. 



Treatment Room Furniture and Equipment 

Dental patient chairs, operator's stools, and equipment 
are designed with asepsis in mind using vinyl upholstery 
with a seamless, easy-to-clean design (Figure 10-20). 
High-speed evacuation (vacuum system), dry, oil-free 
compressed air, and proper patient positioning (made 
easier by having the right chair) all help to control cross- 
contamination. Sterilization of handpieces and air/water 
syringe attachments is required between each patient. 
This amounts to a lot of "spare parts," for each piece of 
equipment in each treatment room. Ample storage must 
be provided for disposables, and space for special waste 
containers must be planned in the treatment room. These 
containers are lined with plastic bags that can be sealed 
before being removed for disposal. Refer to the Modular 
Casework section for more detailed information. 



No Routine Inspection of Asepsis 

Contrary to what many individuals believe, OSHA does 
not regulate asepsis in regard to patients. OSHA's con- 
gressional charter limits it to issues affecting employees 
and their ability to carry out their tasks without exposure 
to hazardous products or serious injury on the job. Until 
the late 1980s when several patients were thought to 
have been infected with HIV by a dentist who had con- 
tracted the disease, most schools of dentistry did not 
teach asepsis and no state asepsis guidelines existed. 
Today, state dental boards and the public health depart- 
ment regulate asepsis in most states. In general dentistry, 



426 Practice of Dentistry 



pedodontics, orthodontics, and endodontics, the goal is 
not to create a sterile field, it is to prevent cross-contami- 
nation. Obviously, there are oral surgery and periodontal 
procedures of an extensive and invasive nature where 
creating a sterile field is necessary and desirable, and 
some of those practitioners employ laminar-flow ventila- 
tion systems in their operatories. Refer to the Sterilization 
section for more specific information on procedures for 
processing dental handpieces and other tools. 



GENERAL DENTISTRY 

Office Circulation Patterns 

Traffic flow within a dental office is from waiting room to 
treatment room, where the dentist greets the patient. 
After an interview about goals and objectives or dental 
problems, X-rays will usually be taken for new patients 
and, for return patients, at certain intervals (Figure 
10-21). Intraoral X-ray is usually available in all treatment 
rooms but, occasionally, as in Figures 10-22 and 10-23, it 
may be located in a separate room. Panoramic and 
cephalometric X-ray is always located in a separate area. 
For subsequent visits during the course of treatment, 
X-rays may or may not be required. The patient should be 
able to enter the operatory and sit down on the right side 
of the chair (for a right-handed dentist) without walking 
around the chair or through the assistant's work area 
(Figure 10-24). At the end of the procedure, the patient 
walks to the reception area, repairs make-up, or combs 
hair at the vanity niche in the corridor (Figures 10-6, 10- 
22, and 10-25) or in the restroom, books a future appoint- 
ment if required, and pays for services. Proper flow pre- 
vents exiting patients from interrupting the reception of 
incoming or new patients (Figures 10-26 and 10-99). 

If the dentist does esthetic/cosmetic procedures, an 
imaging area may be provided where an assistant or 
treatment planning coordinator can take a 35-mm digital 
photo of the patient's smile, download the flash card into 
the computer, and prepare a case presentation or "photo 
album" demonstrating with "before and after" images how 



the patient's smile can be improved through esthetic den- 
tistry (Figures 10-6, 10-97, 10-99, and 10-102). 

The dentist's circulation is from private office to treat- 
ment room and between treatment rooms or operatories. 
He or she should be able to enter the operatory without 
having to walk around the chair or through the assistant's 
work area, wash hands, and position him- or herself on 
the patient's right (if he or she is right handed), as in 
Figure 10-24. The assistant's path is from the treatment 
rooms back and forth to sterilization, laboratory, central X- 
ray room, and film-processing area. The X-ray processing 
area may be a separate darkroom, a film processor with 
a daylight loader attachment (Figure 10-79) in the lab or 
sterilization area, or a special niche, or it might even be a 
digital scanner in a dimly lit alcove such as is required by 
Gendex's DenOptix™ system (Figure 10-74) or Soredex's 
storage phosphor plate systems. The assistant also trav- 
els back and forth from the reception area to escort 
patients in and out of treatment areas. 



GENERAL DENTI ST RY 




Figure 10-21. Schematic diagram of flow in a general dentistry suite. 



General Dentistry 427 



1 




&r(ivnai 



WMTDNQ 

Figure 10-22. Suite plan for general dentistry (pre-ADA), 2516 square feet. (Courtesy: T. Michael Hadley & Associates, ASA, Laguna Hills, CA.) 



428 Practice of Dentistry 



Figure 10-23. Suite plan for general den- 
tistry. {Courtesy: T. Michael Hadley & 
Associates, AIA, Laguna Hills, CA.) 




GENERAL DENTISTRY SUITE 

2516 SF 



General Dentistry 429 



PASS- THRU 
X-RAY BETWEEN 
TWO OPERATORIES 




TRAY/TUB 
PASS- THRU 
UPPER CAB. 



Figure 10-24. Optimal treatment room layout. 



OPTIMAL TREATMENT ROOM 

ALLOWS FREEDOM OF MOVEMENT FOR STAFF AND 
MAXIMIZES EFFICIENCY. THE PRACTITIONER CAN CHOOSE 
ALMOST ANY KIND OF DELIVERY SYSTEM WITH THIS BASIC 
LAYOUT: CHAIR-MOUNTED DELIVERY, SIDE-MOUNTED 
DELIVERY, OR REAR (1 O'CLOCK) DELIVERY FROM A DUO 
CART OR WALL-MOUNTED DELIVERY SYSTEM. THIS ROOM 
CAN BE AMBIDEXTROUS WITH EITHER A CHAIR-MOUNTED 
RIGHT/LEFT SWITCHABLE DELIVERY AND REAR-MOUNTED 
ASSISTANT'S CART OR ARM, THAT SWINGS EQUALLY TO 
BOTH SIDES OF THE CHAIR AND ALLOWS SWITCHING THE 
SIDE OF THE CART THAT THE ASSISTANT'S INSTRUMEN- 
TATION IS DELIVERED FROM. THE PRACTITIONER CAN ALSO 
CHOOSE A DUO REAR DELIVERY CART OR ARM AND KEEP 
THE CHAIR FREE OF ANY CHAIR-MOUNTED DELIVERY. 
NOTE THAT THE OPTIONAL SECOND ASSISTANT (A 2 ) 
WORKS TO THE RIGHT OF THE DENTIST. 




Figure 10-25. Attractive vanity counter and mirror enable patients to check makeup 
or hair prior to exiting; it also makes a good first impression as one enters the 
office. {Photographer: Jain Malkin.) 



430 Practice of Dentistry 




GENERAL DENTISTRY SUITE 

2632 SF 
Figure 10-26. Space plan for general dentistry, 2632 square feet. (Courtesy: T. Michael Hadley & Associates, AIA, Laguna Hills, CA.) 



General Dentistry 431 



Depending on the treatment room layout, the chairside 
assistant (also called the auxiliary) may have to walk the 
greater distance in order to reach his or her work areas 
since it is more important for the dentist to have the short- 
est route (Figures 10-27 and 10-28). However, the opera- 
tory in Figure 10-29 has two entrances, one for the assis- 
tant and one for the dentist. This makes it easy for the 
assistant to enter and leave the room without walking 
behind the chair. Since the dentist and assistant are work- 
ing in such confined areas, it is critical that these spaces 
be well planned and efficient. As with a medical office, a 
dental office should have a private entrance/exit for the 
staff and dentists so that they do not have to pass through 
the waiting room. 



Table 10-1. 

Analysis of Program. 

General Dentistry 



No. of Dentists: